General Aviation Reports

Transcription

National Transportation Safety Board - Aircraft Accident/Incident Database
Accident Rpt# CEN14CA458
08/26/2014 1845 CDT Regis# N8176M
Acft Mk/Mdl BEECH A36-UNDESIGNAT
Acft SN E-2602
Apt: West Houston IWS
Acft Dmg:
Fatal
Eng Mk/Mdl TELEDYNE IO-550-B
Opr Name:
Houston, TX
0
Rpt Status: Factual Prob Caus: Pending
Ser Inj
Opr dba:
0
Flt Conducted Under: FAR 091
Aircraft Fire:
AW Cert: STN
Summary
The pilot said that, shortly after takeoff, the airplane seemed to have a "performance/power loss" and that it was not climbing. Heÿlowered the airplane's nose in
an attempt to gain airspeed and retracted the landing gear. The airplane immediately descended back onto the runway, slid on its belly, and then struck several
approach lights. A Federal Aviation Administration inspector witnessed the accident and said that, after the airplane departed, itÿentered a nose-high,
exaggerated cross-control condition with the airplane's tail only about 10 ft above the runway. Theÿinspectorÿmomentarily lost sight of the airplane, but, when
he saw it again,ÿit had landed on its belly and was sliding off the runway. According to the Pilot's Operating Handbook,ÿthe landing gear should only be
retracted on takeoff once a positive climb rate has been established. No preimpact mechanical deficiencies were identified 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 maintain
airplane control during takeoff. Contributing to the severity of the accident was the pilot's retraction of the landing gear before establishing a positive climb rate,
which resulted in a gear-up landing.
Events
1. Takeoff - Loss of control in flight
Findings - Cause/Factor
1. Personnel issues-Task performance-Use of equip/info-Aircraft control-Pilot - C
2. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Airspeed-Not attained/maintained - C
3. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Altitude-Not attained/maintained - C
4. Environmental issues-Physical environment-Object/animal/substance-Runway/taxi/approach light-Contributed to outcome
5. Personnel issues-Task performance-Use of equip/info-Use of equip/system-Pilot - F
6. Personnel issues-Action/decision-Action-Incorrect action performance-Pilot - F
Narrative
On August 26, 2014, at 1800 central daylight time, N8176M, a Beechcraft A-36 single-engine airplane, sustained substantial damage on takeoff from West
Houston Airport (IWS), Houston, Texas. The private pilot and the three passengers were not injured. An instrument flight rules flight plan was filed for the
personal flight that was destined for Monroe, Louisiana. Visual meteorological conditions prevailed for the personal flight that was conducted under the
provisions of 14 Code of Federal Aviation Regulations Part 91.
The pilot stated that he conducted a preflight inspection and engine run-up before takeoff and everything was normal. He then departed and rotated at 80 knots
and the airplane began to climb. The pilot said, "A couple of seconds into the climb, I seemed to have a performance/power loss - no ability to climb. I leveled
the nose in an attempt to gain airspeed - then slightly down. I engaged the landing gear up-switch, the plane began to descend." The airplane then landed back
on its belly and slid off the runway and struck the runway's precision approach path indicator (PAPI) lights.
A Federal Aviation Administration (FAA) inspector was at the airport and witnessed the accident. He said he watched the airplane depart and cross in front of
him from left to right "with a nose high attitude and in an exaggerated cross control condition." The inspector estimated the tail of the airplane was about 10 feet
above the surface of the runway. The airplane disappeared from the inspector's view for a brief second and the next time he saw the airplane it was sliding on
its belly. The inspector later examined the airplane and reported that it had sustained substantial damage to the fuselage, empennage and firewall. The three
bladed propeller was also damaged. One blade was missing approximately 4 inches from the tip and bent backwards in an arc covering approximately 2/3's of
the blade. The other two blades where intact and were both bent backwards over 2/3 of the blade. No mechanical deficiencies were identified that would have
precluded normal operation of the airplane and engine at the time of the accident.
According to the Beech Bonanza A-36 Pilot Operating Handbook (POH), Section IV, TAKEOFF checklist, the landing gear is only to be retracted once a
positive rate-of-climb is established.
Printed: April 01, 2015
Page 1
an airsafety.com e-product
Prepared From Official Records of the NTSB By:
Air Data Research
9865 Tower View, Helotes, Texas 78023
210-695-2204 - [email protected] - www.airsafety.com
Copyright 1999, 2015, Air Data Research
All Rights Reserved
The pilot held a private pilot certificate for airplane single-engine land. He reported a total of 928 hours, of which, 149 hours were in the same make/model as
the accident airplane.
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Air Data Research
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Accident Rpt# GAA15CA008
Acft Mk/Mdl CESSNA 170A-B
Opr Name:
Page 3
03/12/2015 25 EDT
Regis# N170TW
Palmetto, FL
Acft SN 20197
Acft Dmg: SUBSTANTIAL
Rpt Status: Prelim
Fatal
0
Apt: Airport Manatee 48X
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire: NONE
All Rights Reserved
Accident Rpt# ERA14CA448
09/19/2014 1100 EDT Regis# N13394
Acft Mk/Mdl CESSNA 172M-M
Acft SN 17262725
Leesburg, FL
Acft Dmg:
Fatal
Eng Mk/Mdl LYCOMING O-320 SERIES
Opr Name: MONTE & CO LLC
Apt: Leesburg International LEE
0
Ser Inj
Opr dba:
0
Aircraft Fire:
AW Cert: STN
Summary
The flight instructor and student pilot were conducting practice touch-and-go takeoffs and landings in the airport traffic pattern. The instructor stated that the
runway was wet from rain earlier in the day. During the fifth landing, the student landed the airplane right of the runway centerline. The flight instructor described
the landing as "soft" and "slow." The student applied left rudder to steer the airplane back toward the centerline, but the airplane continued to drift left. The flight
instructor stated that he took the flight controls, applied left rudder, and then applied left brake, but the airplane "did not respond." The airplane subsequently
ran off the left side of the runway, impacted a sign, and came to rest upright about 250 ft past the runway edge. The left main landing gear collapsed, and the
firewall sustained substantial damage. Postaccident examination of the landing gear, wheels, brakes, rudder controls, and nosewheel steering revealed no
anomalies.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The flight instructor's delayed
remedial action and his subsequent loss of directional control during landing on a wet runway for reasons that could not be determined because postaccident
examination of the airplane revealed no anomalies.
Events
1. Landing-landing roll - Loss of control on ground
2. Landing-landing roll - Runway excursion
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-Instructor/check pilot - C
3. Not determined-Not determined-(general)-(general)-Unknown/Not determined - C
4. Environmental issues-Physical environment-Runway/land/takeoff/taxi surface-Wet-Not specified
5. Personnel issues-Action/decision-Action-Delayed action-Instructor/check pilot - C
Narrative
On September 19, 2014, about 1100 eastern daylight time, a Cessna 172M, N13394, was substantially damaged during a runway excursion while landing at
Leesburg International Airport (LEE), Leesburg, Florida. The flight instructor (CFI) and student pilot were not injured. Visual meteorological conditions prevailed,
and no flight plan was filed for the local instructional flight, which was operated under the provisions of Title 14 Code of Federal Regulations Part 91.
The CFI and student were conducting touch-and-go landings in the airport traffic pattern. During the fifth landing of the day, the student pilot landed right of the
runway centerline. The CFI described the landing as "soft" and stated that the airplane's speed at touchdown was "slow." The student applied left rudder to
steer the airplane back to the runway centerline; however, it continued to drift left. The CFI assumed control of the airplane and applied right rudder, which he
said "had no effect," then applied right brake. He stated that the airplane "did not respond," and continued off the left side of the runway, where it impacted a
sign and eventually came to rest upright in the grass. The CFI stated that it had rained earlier in the day, and the runway was wet at the time of the accident.
The airplane was examined after the accident by a Federal Aviation Administration (FAA) inspector. According to the inspector, the left main landing gear had
collapsed aft, and the left portion of the horizontal stabilizer and elevator were substantially damaged. There were no tire skid marks observed on the runway;
however, tire tracks were evident in the grass leading from the runway to where the airplane came to rest, for a distance of about 250 feet. Examination of the
landing gear revealed that all three tires were inflated properly, and turned freely when rotated. Rudder control system continuity was established from the
cockpit to the rudder, with no anomalies noted. Examination of the nose landing gear revealed that both steering rods remained attached to the nose wheel
yoke. Examination of the brakes revealed no anomalies.
The CFI held a commercial pilot certificate with ratings for airplane single- and multi-engine land, rotorcraft-helicopter, and instrument airplane and helicopter;
and a flight instructor certificate with a rating for airplane single-engine. His most recent FAA first class medical certificate was issued in May, 2011. He
reported 413 total hours of flight experience, of which 120 hours were in the accident airplane make and model.
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The airplane was manufactured in 1973, and had accumulated 5,848.2 total hours at the time of its most recent 100-hour inspection on July 23, 2014.
The 1053 weather observation at LEE included wind from 60 degrees at 5 knots, an overcast cloud layer at 11,000 feet, temperature 27 degrees C, dew point
23 degrees C, and an altimeter setting of 30.01 inches of mercury.
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03/19/2015 1700 EDT Regis# N731HG
Acft Mk/Mdl COSTRUZIONI AERONAUTICHE TECNA
Opr Name:
Page 6
Acft SN 1208
Cambridge, MD
Apt: Cambridge-dorchester CGE
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire: NONE
All Rights Reserved
01/29/2014 1515 CST Regis# N24RB
Memphis, TN
Acft Mk/Mdl ENSTROM F 28A
Acft Dmg:
Eng Mk/Mdl LYCOMING HIO 360 C1A
Fatal
Opr Name:
0
Apt: General Dewitt Spain M01
Ser Inj
Opr dba:
0
Aircraft Fire:
Events
2. Landing-flare/touchdown - Sys/Comp malf/fail (non-power)
Narrative
HISTORY OF FLIGHT
On January 29, 2014, about 1515 central standard time, an Enstrom F-28A helicopter, N24RB was substantially damaged during landing at General Dewitt
Spain Airport (M01), Memphis, Tennessee. The flight instructor and private pilot were not injured. The airplane sustained substantial damage to a main rotor
blade and the tail rotor driveshaft. The helicopter was registered to and operated by a flight school under the provisions of 14 Code of Federal Regulations Part
91 as an instructional flight. Visual meteorological conditions prevailed and no flight plan was filed for the local flight that departed M01 about 1340.
According to the flight instructor's written statement, they had practiced several running landings with simulated stuck anti-torque pedal approaches; each
approach varied between the right pedal, left pedal, and neutral position. While the student completed some of the landings, the flight instructor guarded the
cyclic and collective flight controls and, at times, took control of the helicopter and demonstrated the maneuver to completion. The flight instructor reported that
during a low power steep approach the profile and alignment with the landing zone on final approach appeared "correct" and the speed before touchdown was
approximately 10 mph. During touchdown, the landing skids collapsed and the helicopter came to rest in a nose-down attitude.
WRECKAGE AND IMPACT INFORMATION
Post-accident examination of the helicopter by a Federal Aviation Administration (FAA) inspector revealed substantial damage to the tail boom and the tail rotor
drive shaft. According to photographs taken by the FAA inspector, the tail boom was damaged in multiple sections with evidence of bending. The tailrotor drive
shaft was found 100 feet away from the helicopter; one end displayed torsional damage and the other end displayed evidence consistent with shearing. Two of
the three main rotor blades were undamaged and the inboard trailing section of the third main rotor blade was split open. The third main rotor blade also
exhibited compression wrinkles throughout the length of the blade. Examination of the landing skid revealed a broken skid tube clamp which was recovered to
the NTSB materials laboratory for further inspection. The FAA inspector reported no mechanical malfunctions or anomalies with the control system that would
have precluded normal operation.
PERSONNEL INFORMATION
The pilot held a flight instructor certificate with ratings for airplane single-engine land, instrument airplane, and helicopter. He also possessed a commercial
certificate with ratings for single-engine land, multi-engine land, helicopter, instrument airplane, and instrument helicopter. The pilot reported 5,260 total hours of
flight experience, of which about 2,000 hours were in the accident helicopter make and model.
The student held a private pilot certificate with ratings for helicopter and instrument helicopter. He reported 225 total hours of flight experience, of which 142
hours were in the accident helicopter make and model.
AIRCRAFT INFORMATION
The helicopter was a single-engine, three-place helicopter with skid type landing gear. It was manufactured in 1971 and had accrued 10,000 total aircraft hours.
It was powered by a four cylinder, 205 horsepower, Lycoming HIO-360-CIA engine. Its most recent 100 hour inspection was completed on November 22, 2013,
at 9,930 total aircraft hours.
According to the maintenance records, the landing gear was inspected on November 22, 2013 in accordance with the 100 hour inspection checklist which
stated, "Check landing gear for cracks in weld areas, bolts at all attach and pivot points for excessive wear." The maintenance manual does not require the
removal and examination or replacement of any of the skid tube clamps during the lifetime of the helicopter.
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Based on the maintainer's recounted history of the helicopter's time in service, the helicopter had three prior hard landing events that resulted in repairs, but the
maintenance records did not contain any entries related to the examination, repair or replacement of the skid tube clamp in the helicopter's 44 year history.
According to a representative of the airframe manufacturer, the broken skid tube clamp recovered from the wreckage was identified as part #34 in Enstrom IPC
7-51. This particular clamp connected the landing gear leg to the cross tube. He added that the landing gear leg, oleo strut, and the outboard portion of the
cross tube form a triangle. During landing, forces push up on the skid at the bottom corner of the "triangle" where the oleo strut and the leg attach. The "triangle"
will pivot around the upper end of the oleo strut where it attaches to the end of the cross tube, which places the skid tube clamp in tension where the top of the
leg attaches.
The representative of the airframe manufacturer reported multiple landing gear failures in a span of 20 years. During this time the clamps were either broke or
cracked, but the damage was always attributed to overstress due to hard landings, and never examined or evidence of fatigue.
METEOROLOGICAL INFORMATION
The 1454 recorded weather at MEM, located about 9 nautical miles south of the accident site, included calm wind, clear skies, 10 miles visibility, few clouds
25,000 feet, temperature 1 degree C, dewpoint minus 17 degrees C, and an altimeter setting of 30.37 inches of mercury.
ADDITIONAL INFORMATION
Materials Laboratory
The skid tube clamp was composed of two halves, which were affixed on one side by a bolt. The upper clamp half was bent and twisted outward and the
attached ring exhibited features on its fracture surface that were consistent with overstress. The fracture surface of the upper clamp half, opposite a weld,
contained numerous ratchet marks, consistent with progressive cracking from multiple initiation sites. The lower clamp half was fractured near the welded ring;
the clamp half exhibited no indications of plastic deformation. The mating fracture surface, adjacent the weld, displayed fatigue striations indicative of fatigue
crack propagation. Multiple cracks had initiated at the weld where the ring joined the lower clamp and propagated inward through the thickness of the clamp.
Chemical examination of the lower clamp revealed a composition that was consistent with alloy steel. The composition of the ring was also consistent with an
alloy steel; however, different from the clamp and with a notably lower chromium content. The weld material was consistent with commonly used weld filler
steels. Hardness testing revealed that the weld material was soft compared to the clamp and ring, which progressively increased in hardness closer to the weld.
The hardness was highest between the heat-affected zone near the weld and the weld, which corresponds with the fatigue crack initiation areas of the clamp
and ring.
The weld cracks were not visible, and could only be detected by magnetic particle or dye penetrant inspection.
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10/04/2014 1810 EDT Regis# N85707
Maryville, TN
Apt: Kagley Field NONE
Acft Mk/Mdl AERONCA 7AC
Acft SN 7AC-4453
Eng Mk/Mdl CONTIENENTAL MOTORS A&C 65
Acft TT
Fatal
Opr Name: CHARLES W HALL
Opr dba:
1714
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Events
2. Approach-VFR go-around - Loss of lift
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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03/27/2015 1500 CDT Regis# N20062
Acft Mk/Mdl AIR TRACTOR INC AT 602-NO SERIES
Opr Name:
Page 10
Acft SN 602-1198
Ropesville, TX
Apt: Pro Agri Private Air Strip
Rpt Status: Prelim
Fatal
Flt Conducted Under: FAR UNK
0
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire: NONE
All Rights Reserved
Accident Rpt# ANC15LA015
03/13/2015 715 AKD
Acft Mk/Mdl AIRBUS AS350 B2
Regis# N814EH
Anchorage, AK
Acft SN 2641
Rpt Status: Prelim
Acft TT
Fatal
5615
0
Ser Inj
Opr Name: ERICKSON AIR-CRANE INCORPORATED Opr dba:
Apt: N/a
0
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: STN
Events
1. Enroute-cruise - Flight control sys malf/fail
Narrative
On March 13, 2015, about 0715 Alaska daylight time, a turbine-powered Airbus Helicopters AS350-B2, N814EH, sustained substantial damage as a result of a
tail rotor pitch control failure while en route from Merrill Field, Anchorage, Alaska to an off airport landing site near Beluga, Alaska. The flight was being
operated as a visual flight rules (VFR) on-demand commercial flight under Title 14 Code of Federal Regulations (CFR) part 135. The certificated commercial
pilot and two passengers sustained no injuries. Visual meteorological conditions prevailed for the flight. Company flight following procedures were in effect and
a company flight plan was filed and activated.
During an interview with the National Transportation Safety Board (NTSB) investigator-in-charge, along with a Federal Aviation Administration (FAA) aviation
safety inspector on March 13, 2015, the pilot stated that while en route, about 1,000 feet above ground level (AGL), he felt a "clunk" in the tail rotor control
pedals and the helicopter began to yaw to the left. When he attempted to counteract the yaw by depressing the right tail rotor control pedal, there was no
reaction from the helicopter and the right pedal travelled to the forward stop. The pilot declared an in-flight emergency with air traffic control, returned to Merrill
Field, and executed an emergency run-on landing.
A post flight examination of the helicopter revealed the tail rotor pitch change spider assembly, part number 350A33-2030-00, had fractured into multiple pieces,
all with rotational scarring present along the fractured surfaces. The inside of the spider assembly contained dark discoloration consistent with thermal damage.
Light circumferential scarring was present on the tail rotor gear shaft about three inches outboard of the tail rotor gear box, approximately one inch wide.
The fractured tail rotor pitch change spider assembly and the tail rotor gear box were retained. An NTSB metallurgical examination is pending.
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03/18/2015 1000 EST Regis# N43MT
Acft Mk/Mdl AMERICAN CHAMPION AIRCRAFT
Opr Name: ECHO TANGO LLC
Page 12
Greensboro, NC
Apt: Air Harbor W88
Acft SN 402-98
Rpt Status: Prelim
Acft TT
Fatal
1421
0
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire: NONE
All Rights Reserved
Accident Rpt# ERA13LA214
04/25/2013 1806 CDT Regis# N2713T
Knoxville, TN
Apt: Downtown Island Airport DKX
Acft Mk/Mdl BEECH 35-C33A
Acft SN CE-150
Eng Mk/Mdl CONT MOTOR IO 520 SERIES
Acft TT
Fatal
Opr Name: DAVID QUENTIN ELKINS
Opr dba:
3697
0
Ser Inj
1
Aircraft Fire: NONE
Summary
According to the accident pilot, who was also a mechanic at a repair facility that had just completed work on the airplane's engine, the airplane's owner reported
that, during his last flight, the engine began running roughly about 7,500 ft. He stated that the owner also reported that turning on the auxiliary fuel pump caused
the engine to run "smooth" and that he continued the flight uneventfully. Maintenance personnel, including the accident pilot, examined and tested the engine's
induction, ignition, and fuel systems, and the only discrepancy they discovered was that the engine-driven fuel pump inlet fitting was loose.
After the examination, the accident pilot performed a preflight inspection and engine run-up with no anomalies noted. The pilot reported that, before initiating the
takeoff for the postmaintenance check flight, he chose to activate the auxiliary pump as a precautionary measure; however, the Pilot's Operating Handbook, the
pilot's abbreviated checklist, and a placard near the auxiliary fuel pump switch indicated that the auxiliary fuel boost pump should be turned off for takeoff.
During the initial climb, when the airplane was less than 200 ft above the ground, the engine lost power. The pilot's efforts to restore engine power were
unsuccessful, so he performed a forced landing. A postaccident examination and test run of the engine revealed no anomalies that would have precluded
normal operation. Although the pilot did not follow the published takeoff procedures, it could not be determined if his use of the auxiliary fuel boost pump during
takeoff caused the loss of engine power.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The loss of engine power during
takeoff for a reasons that could not be determined because postaccident examinations and testing revealed no anomalies that would have precluded normal
operation.
Events
1. Initial climb - Loss of engine power (partial)
2. Emergency descent - Off-field or emergency landing
3. Landing-flare/touchdown - Collision with terr/obj (non-CFIT)
Narrative
On April 25, 2013, about 1806 central daylight time, a Beech 35-C33A, N2713T, was substantially damaged during a forced landing following a loss of engine
power near Knoxville, Tennessee. The commercial pilot sustained serious injuries. The airplane was registered to a private individual and operated by the
commercial pilot under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the
postmaintenance test flight. The flight departed from Downtown Island Airport (DKX), Tennessee, at 1756.
According to mechanics at a repair facility that just completed work on the accident airplanes engine, the airplane owner reported engine roughness and a fuel
pressure fluctuation at 7,500 feet. He also reported to the repair facility that when he turned on the auxiliary fuel pump, it caused the engine to run "smooth" and
he continued the flight uneventfully. The mechanics went on to say that the when they received the airplane, they checked the fuel screens and checked the
fuel system components.
They performed an extensive ground run up and after everything checked out satisfactory, flew the airplane over to another facility for further inspection. They
continued to inspect the airplane and checked the ignition system, cleaned, gapped, tested all spark plugs and checked the spark plug wires. All of the fuel
screens were checked and no abnormalities were noted. A suction test was performed from the firewall fuel fitting and after 5 gallons of fuel flow, no bubbles
were found to indicate air leaks on either tank selection. All of the fuel tank vents were checked and no blockage was noted. All engine compartment fuel hoses
were cleaned and examined and no anomalies were noted. During the examination it was discovered that the engine-driven fuel pump inlet fitting was loose.
The fitting was removed, cleaned and reinstalled. The fuel flow was tested with the boost pump at the firewall and at the fuel divider; flow was good and
uninterrupted. The fuel strainer was examined and no debris was found. All fittings were reconnected and the system was pressure tested and no leaks were
noted. Several full-power run-ups were conducted, and all were satisfactory. After the full-power run-ups, screens were checked again and found to be clean.
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All performance and operational parameters were normal.
The accident pilot/mechanic was performing a post-maintenance test flight. He did a preflight inspection of the airplane and did a full power run-up with the
auxiliary fuel pump on and off. He checked all aircraft and engine systems prior to departing; no anomalies were noted and all systems checked satisfactory.
Takeoff power, fuel flow and the ground roll were normal. He stated that as a precaution he turned on the auxiliary fuel pump prior to takeoff and the fuel flow
was steady in the green arc. Shortly after rotation the engine began to shutter and the fuel pressure dropped. As the airplane climbed out the pilot/mechanic
reported that approximately 100-200 feet above ground level the engine lost approximately 70%-80% of power then lost all power. He cycled the auxiliary fuel
pump off and on, cycled the mixture, and no changes were noted. The pilot/mechanic went on to say that he could not confirm the total loss of engine power,
since by the sound of the propeller it may have been idling between 600 to 800 rpm while at a full power setting. The airplane was unable to maintain lift and a
forced landing was performed.
According to a Federal Aviation Administration inspector, the airplane came to rest in a field in a residential area, and exhibited substantial damage. Further
examination of the airplane revealed that the right wing outboard leading edge was buckled aft. The engine was broken away from the firewall and engine
mounts. The engine was removed from the airframe and it was determined that it could be test run. The engine was sent to Continental Motors Incorporated
under the oversight of the NTSB. The engine was re-inspected prior to the test run and impact damage was noted on the engine. During the preparation for the
test run minor parts were replaced.
During the testing of the engine it started immediately during the first attempt. The engine ran for 10 minutes before it suddenly lost power; this was attributed to
a distortion noted at the throttle body due to impact damage. The fuel was confirmed to and from the fuel manifold. The engine was restarted and a magneto
check was performed. The engine was shut down and restarted and ran at full power for approximately 20 minutes without any abnormalities. The engine was
shut down and allowed to cool and restarted. An additional engine test run was performed and no abnormalities were noted. The magnetos were bench tested
and partially dissembled with no discrepancies noted.
A review of the pilot operating handbook and pilot's abbreviated checklist revealed that the published procedures and limitations stated: prior to takeoff the
auxiliary fuel pump should be turned off for takeoff. The airplane was also placarded stating that the "AUX FUEL PUMP OPERATION" for takeoff and landings
should be left in the off position except in the case of loss fuel pressure.
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03/04/2015 952 EST
Acft Mk/Mdl BEECH 58
Opr Name: BRICK STREET INSURANCE
Page 15
Regis# N50NH
Monroe, NC
Acft SN TH-1030
Acft Dmg:
Acft TT
Fatal
4933
0
Apt: Charlotte-monroe County EQY
Rpt Status: Prelim
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire:
All Rights Reserved
Accident Rpt# CEN14LA253
05/26/2014 1640 CDT Regis# N188DP
Rockdale, TX
Apt: H.h. Coffield Regional KRCK
Acft Mk/Mdl BEECH A36
Acft SN E-1476
Eng Mk/Mdl CONTINENTAL IO-520-BB87
Acft TT
Fatal
Opr Name: PILOTS CHOICE AVIATION INC
Opr dba:
5360
0
Ser Inj
0
Aircraft Fire: NONE
Summary
The pilot reported that, about 20 minutes into the flight, the engine sound abruptly changed, and the engine began to lose power. The pilot's attempts to restore
power were unsuccessful. An air traffic controller gave the pilot radar vectors to the nearest airport; however, the airplane was unable to glide to the runway, so
the pilot made a forced landing on uneven terrain. The right main landing gear did not extend fully before touchdown, and the airplane ground looped, which
resulted in the fuselage buckling and the outboard portion of the right wing being torn off. The engine was test run at all power settings, and no anomalies were
noted.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: A loss of engine power for
reasons that could not be determined because postaccident testing revealed no anomalies.
Events
1. Enroute-cruise - Loss of engine power (total)
3. Landing - Collision with terr/obj (non-CFIT)
Narrative
On May 26, 2014, about 1840 central daylight time, a Beech A36, N188DP, was substantially damaged when the engine lost power and the pilot made a forced
landing on a road near Rockdale, Texas. The pilot and three passengers on board were not injured. The airplane was registered to and operated by Pilots
Choice Aviation, Inc., Georgetown Texas, under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions
prevailed at the time of the accident, and an instrument flight rules flight plan had been filed. The flight originated from Huntsville Municipal Airport (KUTS),
Huntsville, Texas, at 1825, and was en route to Georgetown Municipal Airport (KGTU), Georgetown, Texas.
According to the pilot's statements, both main fuel tanks were filled to capacity, but the auxiliary tanks were not serviced. The first leg of the flight from New
Orleans, Louisiana, to Huntsville, Texas, was uneventful. The pilot elected to go to Huntsville due to the weather conditions in the Austin, Texas, area. After
spending several hours at Huntsville, the pilot and his family departed for Georgetown. About 20 minutes into the flight, the engine made "an abrupt change in
sound" and the engine began to lose power. All cylinder EGTs (exhaust gas temperature) were above 1500 degrees Celsius (C.) Switching from the right tank
to the left tank did not restore power, so the pilot returned the selector to the right tank. The pilot advanced the mixture, throttle, and propeller control full
forward and noticed the cylinder EGTs were registering 200 degrees. He advised air traffic control that his engine was losing power and was given radar vectors
to the H.H. Coffield Regional Airport (KRCK), about 4 miles southwest of the flight's position. The pilot subsequently declared an emergency. Unable to glide to
the runway, the pilot made a forced landing on uneven terrain near County Road 322. The right main landing gear did not extend fully prior to touch down and
the airplane ground looped. The fuselage was buckled and the outboard portion of the right wing was torn off.
Under the auspices of the National Transportation Safety Board, the engine was functionally tested at Air Salvage of Dallas in Lancaster, Texas, on July 21.
The engine tested satisfactory at all power settings and no anomalies were noted.
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05/23/2013 1456 EDT Regis# N8225T
Atlanta, GA
Apt: Dekalb-peachtree Airport PDK
Acft Mk/Mdl BEECH A36
Acft SN E-2801
Eng Mk/Mdl CONT MOTOR IO-550-B
Acft TT
Fatal
Opr Name: BONANZA FIVE INC
Opr dba:
3763
0
Ser Inj
0
Aircraft Fire: NONE
Summary
The pilot reported that, before the flight, he checked the weather and obtained a full weather briefing from flight service. After he boarded the passengers and
loaded the luggage into the airplane, the pilot conducted a preflight inspection and noted that everything was "good." During taxi, he asked the air traffic
controller if he could take off from runway 3R because it was the longest runway. He then conducted an engine run-up and noted that everything was normal.
While holding short of the runway, the pilot heard another pilot ask the controller for a wind check, and the controller replied that the wind was from 300
degrees. Because that would result in a direct crosswind for runway 3R, the pilot asked if runway 34 was available, and the controller replied that it was closed.
While waiting for departure, the pilot noted that the windsock seemed to be indicating a slight quartering tailwind. During the takeoff, he applied left aileron
because of the crosswind. As he rotated the airplane, "something didn't feel right." The stall warning horn then started "chirping," and the airplane turned into
the wind and did not take off with "its usual vigor." He leveled off to stop the stall horn and stated that the engine didn't sound right. He decided to abort the
takeoff when the airplane was about 30 ft above ground level (agl). He reduced power and tried to glide the airplane to land. However, shortly thereafter, the
stall warning horn "blared," and the airplane entered an aerodynamic stall and impacted the runway. Examination of the wreckage and recorded engine monitor
data revealed no evidence of failures or malfunctions.
One of the passengers recorded the takeoff and accident sequence on his cell phone. The video showed that, after the pilot rotated the airplane for takeoff, the
stall warning horn sounded; the airplane was in a nose-high attitude and had reached an altitude of between 50 and 100 feet agl when the pilot reduced the
power. The video then showed the airplane descending until the sound of impact was heard. During the takeoff, the engine sounded constant and normal.
The reported wind about the time of the accident was 290 degrees at 13 knots gusting to 18 knots. According to the Aircraft Flight Manual/Pilot's Operating
Handbook (AFM/POH), these conditions would have resulted in a crosswind component that, during portions of the takeoff and initial climb, would have
exceeded the airplane's maximum demonstrated crosswind of 17 knots and would have resulted in a 2- to 4-knot tailwind component. Further, two pilots
reported low-level windshear at the airport about the time of the accident. No convective echoes existed in the local area about the time of the accident;
therefore, a microburst event did not occur at the airport at the time of the accident. High-density altitude conditions existed around the time of the accident,
which would also have degraded the airplane's performance and increased the distance needed for the takeoff roll. The pilot should have accounted for the
crosswind, the tailwind, and the high-density altitude conditions in his preflight planning, but he did not do so.A review of the pilot's weight and balance
calculations revealed that he underestimated the occupant and baggage weights in his calculations and used an inaccurate airplane empty weight.
Recalculations using accurate weights revealed that the airplane was operating at least 100 pounds over the published maximum takeoff weight at the time of
the accident and that the center of gravity (CG) was farther aft than the pilot had calculated. The AFM/POH performance charts only provide data for operating
up to the airplane's maximum takeoff weight; it cautions that if loaded above the maximum takeoff weight, the takeoff distance will be longer, the stall speed will
be higher, and the climb rate will be lower than that shown in the performance charts.
Pilots are expected to perform airplane performance calculations and determine takeoff distances using accurate weight and balance information and taking
into account other important factors, such as wind and pressure conditions, that can affect climb performance and takeoff distance. However, the accident pilot
did not properly calculate the airplane's weight and balance during his preflight calculations, and he overloaded the airplane at an aft CG, which would have
degraded the airplane's performance. Further, he did not account for the high-density altitude or wind conditions at the airport at the time of the accident, which
would have further degraded the airplane's performance. Therefore, it is likely that the airplane was not able to achieve a positive climb rate and that its nose
was pitched up due to the combined effects of these conditions, which led it to exceed its critical angle-of-attack and subsequently stall.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's inadequate preflight
planning, which resulted in the airplane being loaded in excess of its maximum gross weight at an aft center of gravity for a takeoff with a quartering tailwind
and high-density altitude conditions, all of which degraded the airplane's climb performance and led to the airplane exceeding its critical angle-of-attack and
experiencing an aerodynamic stall.
Events
1. Prior to flight - Aircraft loading event
2. Initial climb - Aerodynamic stall/spin
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3. Initial climb - Loss of control in flight
4. Uncontrolled descent - Collision with terr/obj (non-CFIT)
1. Personnel issues-Task performance-Use of equip/info-Use of manual-Pilot - C
2. Personnel issues-Task performance-Planning/preparation-Weight/balance calculations-Pilot - C
3. Personnel issues-Task performance-Planning/preparation-Performance calculations-Pilot - C
4. Personnel issues-Action/decision-Info processing/decision-Decision making/judgment-Pilot - C
5. Aircraft-Aircraft oper/perf/capability-Aircraft capability-CG/weight distribution-Incorrect use/operation - C
6. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Climb rate-Not attained/maintained - C
8. Aircraft-Aircraft oper/perf/capability-Aircraft capability-Maximum weight-Capability exceeded - C
10. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Angle of attack-Not attained/maintained - C
11. Aircraft-Aircraft oper/perf/capability-Aircraft capability-Maximum crosswind component-Capability exceeded - C
12. Environmental issues-Conditions/weather/phenomena-Temp/humidity/pressure-High density altitude-Effect on equipment - C
13. Environmental issues-Conditions/weather/phenomena-Wind-Crosswind-Effect on equipment - C
Narrative
HISTORY OF FLIGHT
On May 23, 2013, about 1456 eastern daylight time a Beech A36, N8225T, operated by Bonanza 5 Incorporated, was substantially damaged when it entered
an aerodynamic stall and impacted terrain shortly after takeoff at DeKalb-Peachtree Airport (PDK), Atlanta, Georgia. The private pilot and four passengers were
not injured. Visual meteorological conditions prevailed, and an IFR flight plan had been filed for the personal flight destined for Venice Municipal Airport (VNC),
Venice, Florida, which was conducted under Title 14 Code of Federal Regulations Part 91.
According to the pilot, the purpose of the flight was to fly to VNC for fuel and then continue on to their final destination, Key West International Airport (EYW),
Key West, Florida. In anticipation of having a "full load" of passengers and baggage, two days before the trip the pilot had fueled the airplane up to the "slots",
which equated to 70 gallons of usable fuel onboard. On the day of the flight, he checked the weather and obtained a full weather briefing from flight service
before leaving for the airport.
When he and his passengers arrived at the airport, they loaded their possessions into the airplane and the pilot conducted a preflight inspection of the airplane.
Everything was "good" and they pulled the plane out of the hangar, put their cars in the hangar, and got in the airplane. He then started the engine and started
to taxi. One of the passengers however, had left his iPad in the hangar, so he taxied back to the hangar, shut down, and the passenger retrieved it.
When the passenger returned, the pilot started the airplane again and taxied out to the end of the row of hangars, obtained the field conditions from the airport
terminal information service, received his IFR clearance to VNC, then his clearance to taxi, and set the altimeter setting in the Kollsman window. He was
cleared to taxi to runway 3L but, asked for runway 3R as he preferred to use runway 3R which was the longest runway at PDK. He then taxied to the run up
area for runway 3L and completed the run up. Again, everything was normal.
He was then cleared to cross 3L and hold short of 3R while waiting for release from air traffic control. There was a King Air behind him and he was asked to
move over to let him by, which he did. Around this time, someone asked for a wind check and the tower replied that the wind was from 300 degrees (a direct
cross wind). He then asked if Runway 34 was available and was told it was closed because of an air show. Then while they were waiting, or when they were
cleared to depart, he looked at the wind sock and it seemed to be indicating a slight quartering tailwind.
He performed a static takeoff, and double checked that all instruments were normal and in the green before releasing the brakes. At 50 knots indicated
airspeed he cross-checked the instruments and everything was normal. He would normally try and rotate around 80-84 Knots and leave the landing gear down
as long as there was runway remaining. He could not recall exactly what speed he rotated at, but it was "probably around 80 knots". Because of the cross wind,
he applied left aileron during the takeoff. As he rotated, something didn't feel right. The stall warning horn started "chirping", the plane then turned into the wind,
and did not takeoff with "its usual vigor". He leveled off to stop the stall horn and it still didn't feel right. The engine also didn't sound right. He believed that
something was wrong and that he should abort the takeoff. He was not sure of his exact altitude at this point, but guessed that he was probably 30 feet above
ground level. The engine, or prop, still didn't sound right. He still had runway remaining ahead of him and the landing gear was still down, so he radioed that he
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was "putting it back down". He decided to land on the runway and not risk an over run, so he reduced power and tried to glide it in. Shortly thereafter, the stall
warning horn "blared", the airplane entered an aerodynamic stall and impacted the runway.
According to Federal Aviation Administration (FAA) and pilot records, the pilot held a private pilot certificate with ratings for airplane single-engine land,
multi-engine land, and instrument airplane. His most recent application for a FAA third-class medical certificate was dated October 28, 2012. The pilot reported
that he had accrued 613 total hours of flight experience, of which 306 hours were in the accident airplane make and model.
According to FAA and airplane maintenance records, the airplane was manufactured in 2006. The airplane's most recent annual inspection was completed on
March 14, 2013. At the time of the accident the airplane had accrued 3,763 total hours of operation.
The following meteorological information was derived from multiple sources:
Recorded Weather
The recorded weather at PDK, at 1456, included: winds from 290 degrees at 13 knots gusting to 18 knots, 10 miles visibility, few clouds at 5,000 feet, scattered
clouds at 6,500 feet, temperature 28 degrees C, dew point 16 degrees C, and an altimeter setting of 29.98 inches of mercury.
Density Altitude
Calculations using the recorded temperature, station pressure, and dew point, for PDK indicated, that the density altitude for the airport was, approximately
2,899 feet above sea level around the time of the accident.
Synoptic Conditions
The National Weather Service (NWS) Surface Analysis chart for 1400 edt, depicted a cold front extending across eastern Kentucky, Tennessee, into northern
Alabama, Mississippi, into Louisiana moving southeastward. The chart depicted a relative weak pressure gradient across the area with wind from the
west-northwest at about 10 knots across northern Georgia.
The NWS NEXRAD Mosaic of WSR-88D radars across the southeast indicated no significant meteorological echoes in the Atlanta vicinity at 1450 edt.
Pilot Reports
There were 2 pilot reports of low-level wind shear reported at 1420 and 1840 EDT from aircraft landing at KPDK, and reported wind shear of plus or minus 10 to
15 knots within the lowest 200 feet agl of runway 3R.
Sounding
The Atlanta-Peachtree City 0800 sounding depicted a frontal inversion immediately above the surface to about 1360 feet. The sounding had a relative humidity
greater than 80 percent from the surface to 8,000 feet. The wind profile indicated a surface wind from the west or 285 degrees at 4 knots with wind veering to
the northwest immediately above the inversion to 5,000 feet and then backing to the west with height. A low level wind maximum was identified at 2,000 feet
with the wind from 320 degrees at 23 knots. As a result a low-level turbulence potential existed within the lowest 1,000 feet of the surface. The mean 0 to 6
kilometer or 18,000 feet wind from 278 degrees at 22 knots.
Satellite
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The Geostationary Orbiting Environmental Satellite (GOES-14) visible image at 1445 depicted scattered fair weather cumulus clouds surrounding the area. No
cumulonimbus or cumulus congestus type clouds were identified in the vicinity that could have produced any microburst type activity, and no outflow
boundaries were identified for any significant shifts in wind direction
Radar
The NWS Atlanta WSR-88D radar depicted no meteorological echoes in the vicinity during the period, only ground cluster associated with the surface based
temperature inversion and false echoes.
AIRPORT INFORMATION
DeKalb-Peachtree Airport was located approximately 8 miles northeast of the city of Atlanta, Georgia.
According to the Airport Facility Directory, PDK had four runways oriented in a 3R/21L, 16/34, 3L/21R, and 9/27 configuration. Runway 3R was concrete,
grooved, and in good condition. The total length of the runway was 6,001 feet, and its width was 100 feet.
It was equipped with nonprecision runway markings, in good condition, high intensity runway edge lights, and runway end identifier lights.
FLIGHT RECORDERS
The airplane was not equipped with a cockpit voice recorder (CVR) or a flight data recorder (FDR), nor was it required to be equipped with a CVR or FDR under
the CFRs. The airplane was however, equipped with an engine monitoring system that had recording capability, and one of the passengers had a cell phone
that was capable of recording video which was operating during the takeoff and initial accident sequence.
Engine Monitor
The J.P. Instruments (JPI) EDM-700 was a panel mounted instrument enabling the operator to monitor and record up to 24 parameters related to engine
operations. Depending on the installation, engine parameters monitored could include: exhaust gas temperature (EGT), cylinder head temperature (CHT), oil
pressure and temperature, manifold pressure, outside air temperature, turbine inlet temperature (TIT), engine revolutions per minute, compressor discharge
temperature, fuel flow, carburetor temperature, and battery voltage. The unit could also calculate, in real-time, horsepower, fuel used, shock cooling rate and
EGT differentials between the highest and lowest cylinder temperatures. The calculations were also based on the aircraft installation.
The unit contained non-volatile memory for data storage of the parameters recorded and calculated. The rate at which the data was stored was selectable by
the operator from 2 to 500 seconds per sample. The memory could store up to 20 hours of data at a 6 second sample rate. The data could then be downloaded
by the operator using J.P. Instruments software.
The unit was in good condition and data was extracted normally. The unit contained recorded data over 13 power cycles, recorded at a sample rate of once
every 6 seconds. The recorded data spanned dates of April 27, 2013 through the accident flight on May 23, 2013, as recorded by the unit internal clock. The
parameters recorded were EGT, CHT, voltage, and fuel flow. Additionally, the calculated shock cooling rate and maximum difference between EGT sensors
was also recorded. No other parameters were recorded by the unit.
When the unit was powered on, it displayed 71 gallons of fuel remaining and 2 gallons of fuel used. The EDM-700 recorded time of the first data sample based
on the unit's internal clock. This clock was set and updated by the operator. Examination of the recorded data, and comparison with the reported accident time,
indicated the EDM-700 internal clock was set to Coordinated Universal Time (UTC), but was 10 minutes ahead of actual UTC. As such, 10 minutes was
subtracted from all EDM-700 recorded times to correct for the error.
Review of the data revealed that, fuel flow began to increase above 5 gallons per hour (gph) at approximately 14:47:08 achieving a value of about 26 gph by
14:47:20. Coincident with the fuel flow increase, the EGT and CHTs also increased. At about 14:47:44, the fuel flow began to decrease from 26 gph, reaching 5
gph by 14:47:56 and then 0 gph by the end of the recording at 14:48:08. Throughout the recording, CHT-5 was the coolest recorded cylinder.
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Cell Phone
The video file that was retrieved from the cell phone was in an MP4 format of 1920 X 1080 resolution at 29.97 frames per second with a 48000Hz audio track.
The video was recorded with the cell phone oriented in a vertical position, causing the file to be cropped and two black bars added to either side of the video to
maintain a 16:9 aspect ratio.
The video was shot by a rearward facing passenger, on the right side of the airplane. The video captured the view out of the right rear passenger window
looking toward the airplane's right horizontal stabilizer. As the video progressed, a portion of the airplane's cabin was captured including a view of the baggage
storage area and another passenger sitting in the rearmost, forward facing seat, on the left side of the cabin. An additional passenger was also seen briefly as
the camera panned during the recording. The video was 36 seconds and 19 frames in length (36.43 seconds).
Time in the video is expressed as video elapsed time, which is the time from the beginning of the recording. Times are expressed as SSFF, where SS
represents seconds and FF frames of video elapsed time. Additionally, the video elapsed time in seconds has been added in parentheses immediately
following the convention noted above.
The video began with a view out of the right rear window during the takeoff roll, with the airplane accelerating on the ground. The recorded engine noise on the
audio track sounded constant and healthy, which concurred with the data that was downloaded from the engine monitor. At 1018 (10.6 sec.) as the airplane
continued its takeoff roll, the camera began to pan toward the interior of the airplane. As the camera panned right, at 1408 (14.26 sec.), the reference to the
horizon was lost As the camera panned inside the airplane a view of the baggage area was shown and a young adult male was seen reading in the left rear
forward facing seat. The baggage area was noted to have an amount of luggage (restrained by a cargo net) great enough to fill the cabin to the ceiling.
Additional baggage could also be seen piled up on the floor in front of the cargo net area. The camera continued to pan right, and at 1418 (14.6 sec.), the
horizon became visible again, outside of the left rear passenger window. At approximately 1515 (15.5 sec.) an airplane pitch change in the positive (up)
direction was observed and the airplane rotated for takeoff. Almost immediately after rotation however, at 1602 (16.06 sec.), the stall warning horn was heard to
annunciate. The airplane continued in a nose up attitude as the camera panned camera right, at 1701 (17.03 sec.), the left side, rearward facing, adult
passenger, was captured. At this instant the stall warning alarm was intermittent at a high rate.
Between 1800 (18.0 sec.) and 1900 (19.0 sec.), the stall warning alarm briefly ceased, and little change in pitch attitude was noted, which indicated that the
airplane was still pitched nose up. At 2006 (20.2 sec.), the stall warning horn was heard again, and it continued to fluctuate in frequency. At 2020 (20.66 sec.),
the camera panned back toward the left rear, forward facing, passenger, and the airplane was noted to be in a nose high attitude. At 2300 (23.0 sec.), the
horizon was visible again. At this moment, the camera panned back to the left outside of the right rear window, and showed that the airplane was in a nose high
attitude. Between 2500 (25.0 sec.) and 2700 (27.0 sec.) a sound similar to a very slight engine surge was noted. At 3001 (30.03 sec.), the airplane appeared to
have reached its highest altitude (50 to100 feet above the runway surface). At the same instant, the engine noise reduced by a significant amount. By 3311
(33.36 sec.), the camera showed the elevator control surface exhibiting a range of motion between neutral and a positive pitch command which continued until
the end of the recording. At 3316 (33.53 sec.), the stall warning horn became steady for the remainder of the recording. The airplane was in an obvious descent
and at 3505 (35.16 sec.), the elevator could last be seen exhibiting a significant pitch up command. The camera then rapidly changed its field of view, and at
3529 (35.96 sec.) the sound of impact was heard. The recording terminated at 3613 (36.43 sec.).
Examination of the airplane by a Federal Aviation Administration inspector revealed no evidence of any preimpact failure or malfunction of the airplane that
would have precluded normal operation. Further examination revealed that, the airplane had incurred substantial damage to the wings and fuselage.
TESTS AND RESEARCH
Weight and Balance
Review of the pilot's weight and balance revealed that he had calculated that the airplane was approximately 5 pounds below its maximum takeoff weight of
3,650 pounds. Further review revealed however that the empty weight listed did not agree with either the empty weight that was in the airplane flight manual /
pilot's operating handbook (AFM/POH) or any of the flying club's weight and balance sheets that was supplied to members for the airplane.
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Review of flying club documents also revealed that the equipment both onboard and installed on the airplane had changed over the years however, it was
discovered that all of the changes were not reflected in the airplane's equipment list in the AFM/POH.
Review of the video recording had revealed that the baggage area had an amount of luggage (restrained by a cargo net) great enough to fill the cabin to the
ceiling, and that additional baggage could also be seen piled up on the floor in front of the cargo net area. Review of the pilot's weight and balance however
indicated that only 15 pounds of baggage was stowed in the aft luggage area.
There were five occupants onboard the airplane. Comparison of the occupants weights listed on the pilot's weight and balance to the occupant weights provided
to the NTSB, indicated the total occupant weight was greater than originally calculated by the pilot.
According to the pilot, he advised that he had 67 gallons of fuel onboard at takeoff. Review of his weight and balance and the fuel indicating system revealed
that there was at least 70 gallons (420 pounds) of fuel onboard when the airplane came to rest.
Further review of the pilot's weight and balance and reweighing of the baggage revealed that the airplane at the time of the accident was at least 100 pounds
over its maximum takeoff weight, and that the center of gravity of the airplane was further aft than originally calculated by the pilot.
Performance Information
Examination of the weather conditions revealed that the winds at the time were approximately 290 degrees at 13 knots gusting to 18 knots. According to the
AFM/POH this would have resulted in a crosswind component which during portions of the takeoff and initial climb would have exceeded the manufacturer's
demonstrated crosswind of 17 knots and would have resulted in a tailwind component of 2 to 4 knots.
Further review of the AFM/POH also revealed that the performance charts only provided data for operation up to the airplane's maximum takeoff weight.
Therefore, though the airplane's performance would have been degraded due to the airplane being loaded above its maximum takeoff weight and aft of the
calculated center of gravity originally calculated by the pilot, accurate performance of the airplane could not be determined with the published information
available.
It was discovered however, that even though the performance charts were unusable to determine performance if operating above the airplane's maximum
takeoff weight, the airplane manufacturer had included guidance in the AFM/POH on not operating above the maximum takeoff weight and maintaining center of
gravity, advising that maintaining center of gravity within the approved envelope throughout the planned flight is an important safety consideration.
It further advised that the airplane must be loaded so as not to exceed the weight and center of gravity (CG) limitations, and those airplanes that are loaded
above the maximum takeoff or landing weight limitations will have an overall lower level of performance compared to that shown in the Performance section of
the AFM/POH.
The AFM/POH also cautioned that If loaded above maximum takeoff weight, takeoff distance and the landing distance would be longer than that shown in the
Performance section; the stalling speed would be higher, rate of climb, the cruising speed, and the range of the airplane at any level of fuel will all be lower than
shown in the performance section of the AFM/POH.
It further cautioned, if an airplane is loaded so that the CG is forward of the forward limit, it will require additional control movements for maneuvering the
airplane with correspondingly higher control forces and that the pilot may have difficulty during takeoff and landing because of elevator control limits, and if an
airplane is loaded aft of the aft CG limitation, the pilot would experience a lower level of stability.
Airplane characteristics that indicate a lower stability level are; lower control forces, difficulty in trimming the airplane, lower control forces for maneuvering with
attendant danger of structural overload, decayed stall characteristics, and a lower level of lateral-directional damping.
Pilot's Handbook of Aeronautical Knowledge
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According to the Pilot's Handbook of Aeronautical Knowledge (FAA-H-8083-25A), the effect of gross weight on takeoff distance is significant and proper
consideration of this item must be made in predicting the aircraft's takeoff distance. Increased gross weight can be considered to produce a threefold effect on
takeoff performance:
1. Higher lift-off speed.
2. Greater mass to accelerate.
3. Increased retarding force (drag and ground friction).
If the gross weight increases, a greater speed is necessary to produce the greater lift necessary to get the aircraft airborne at the takeoff lift coefficient. As an
example of the effect of a change in gross weight, a 21 percent increase in takeoff weight will require a 10 percent increase in lift-off speed to support the
greater weight. A change in gross weight will change the net accelerating force and change the mass that is being accelerated. If the aircraft has a relatively
high thrust-to-weight ratio, the change in the net accelerating force is slight and the principal effect on acceleration is due to the change in mass.
For example, a 10 percent increase in takeoff gross weight would cause:
- A 5 Percent increase in takeoff velocity.
- At least a 9 percent decrease in rate of acceleration.
- At least a 21 percent increase in takeoff distance.
The effect of wind on takeoff distance is also large, and proper consideration also must be provided when predicting takeoff distance. The effect of a tailwind
requires the aircraft to achieve a greater groundspeed to attain the lift-off speed. A tailwind that is 10 percent of the takeoff airspeed will increase the takeoff
distance approximately 21 percent.
Density altitude also has specific effects on takeoff performance. An increase in density altitude can produce a twofold effect on takeoff performance:
1. Greater takeoff speed.
2. Decreased thrust and reduced net accelerating force.
The effect of density altitude on powerplant thrust also depends much on the type of powerplant. In the case of an unsupercharged reciprocating engine, an
increase in altitude above standard sea level will bring an immediate decrease in power output.
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08/26/2014 1845 CDT Regis# N8176M
Houston, TX
Apt: West Houston IWS
Acft Mk/Mdl BEECH A36-UNDESIGNAT
Acft SN E-2602
Eng Mk/Mdl TELEDYNE IO-550-B
Acft TT
Fatal
Opr Name: N8176M LLC
Opr dba:
4107
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Summary
The pilot said that, shortly after takeoff, the airplane seemed to have a "performance/power loss" and that it was not climbing. Heÿlowered the airplane's nose in
an attempt to gain airspeed and retracted the landing gear. The airplane immediately descended back onto the runway, slid on its belly, and then struck several
approach lights. A Federal Aviation Administration inspector witnessed the accident and said that, after the airplane departed, itÿentered a nose-high,
exaggerated cross-control condition with the airplane's tail only about 10 ft above the runway. Theÿinspectorÿmomentarily lost sight of the airplane, but, when
he saw it again,ÿit had landed on its belly and was sliding off the runway. According to the Pilot's Operating Handbook,ÿthe landing gear should only be
retracted on takeoff once a positive climb rate has been established. No preimpact mechanical deficiencies were identified that would have precluded normal
operation.
Cause Narrative
airplane control during takeoff. Contributing to the severity of the accident was the pilot's retraction of the landing gear before establishing a positive climb rate,
which resulted in a gear-up landing.
Events
4. Environmental issues-Physical environment-Object/animal/substance-Runway/taxi/approach light-Contributed to outcome
5. Personnel issues-Task performance-Use of equip/info-Use of equip/system-Pilot - F
6. Personnel issues-Action/decision-Action-Incorrect action performance-Pilot - F
Narrative
On August 26, 2014, at 1800 central daylight time, N8176M, a Beechcraft A-36 single-engine airplane, sustained substantial damage on takeoff from West
Houston Airport (IWS), Houston, Texas. The private pilot and the three passengers were not injured. An instrument flight rules flight plan was filed for the
personal flight that was destined for Monroe, Louisiana. Visual meteorological conditions prevailed for the personal flight that was conducted under the
provisions of 14 Code of Federal Aviation Regulations Part 91.
The pilot stated that he conducted a preflight inspection and engine run-up before takeoff and everything was normal. He then departed and rotated at 80 knots
and the airplane began to climb. The pilot said, "A couple of seconds into the climb, I seemed to have a performance/power loss - no ability to climb. I leveled
the nose in an attempt to gain airspeed - then slightly down. I engaged the landing gear up-switch, the plane began to descend." The airplane then landed back
on its belly and slid off the runway and struck the runway's precision approach path indicator (PAPI) lights.
A Federal Aviation Administration (FAA) inspector was at the airport and witnessed the accident. He said he watched the airplane depart and cross in front of
him from left to right "with a nose high attitude and in an exaggerated cross control condition." The inspector estimated the tail of the airplane was about 10 feet
above the surface of the runway. The airplane disappeared from the inspector's view for a brief second and the next time he saw the airplane it was sliding on
its belly. The inspector later examined the airplane and reported that it had sustained substantial damage to the fuselage, empennage and firewall. The three
bladed propeller was also damaged. One blade was missing approximately 4 inches from the tip and bent backwards in an arc covering approximately 2/3's of
the blade. The other two blades where intact and were both bent backwards over 2/3 of the blade. No mechanical deficiencies were identified that would have
precluded normal operation of the airplane and engine at the time of the accident.
According to the Beech Bonanza A-36 Pilot Operating Handbook (POH), Section IV, TAKEOFF checklist, the landing gear is only to be retracted once a
positive rate-of-climb is established.
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The pilot held a private pilot certificate for airplane single-engine land. He reported a total of 928 hours, of which, 149 hours were in the same make/model as
the accident airplane.
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Accident Rpt# ERA14FA075
12/18/2013 1110 EST Regis# N3705Z
Acft Mk/Mdl BEECH A36TC
Acft SN EA-146
Eng Mk/Mdl CONTINENTAL TSIO-520
Acft TT
Fatal
Opr Name: GREGORY VOIT
Opr dba:
5555
Chatlottesville, VA
1
Ser Inj
Apt: Charlottesville-albemarle Arpt CHO
0
Aircraft Fire: NONE
Summary
About 1 hour 30 minutes into the cross-country flight and while on approach to the destination airport, the pilot reported a loss of engine power. The pilot was
unable to glide the airplane to the airport, and it subsequently impacted trees and the ground in a residential area about 3 miles from the airport.
The pilot had completely fueled the airplane before departure, and adequate fuel remained onboard at the time of the engine power loss. Examination of the
wreckage revealed that the three-position fuel selector handle was positioned in between the left and right tank detents, which would have restricted fuel flow to
the engine. A subsequent test run of the engine was performed successfully, and no evidence of mechanical malfunctions or failures was found that would
have precluded normal engine operation. The airplane's before landing checklist instructed the pilot to move the fuel selector valve to the fuller fuel tank for
landing. It is likely that, while on approach and preparing the airplane to land, the pilot switched fuel tanks and then inadvertently failed to ensure that the fuel
selector handle was fully positioned in the detent of the fuel tank he intended to select. During the impact sequence, the pilot's shoulder harness separated,
and his cause of death was attributed to blunt force trauma to the torso. The autopsy also reported a near-complete transection of the thoracic aorta. If the
pilot's shoulder harness had remained intact, the risk of traumatic transection of the aorta would have been significantly reduced and, thus, the pilot likely would
only have incurred serious, not fatal, injuries. Examination of the shoulder harness revealed that the belt had separated about 31 inches from where the
fastener connected to the lapbelt. The location of the separation corresponded approximately to where the belt would pass through the D-ring behind the pilot's
shoulder. The belt separation area exhibited about 0.25-inch fraying on one edge and 1.25-inch fraying on the other edge along a total area of about 7.75
inches. The shoulder harness manufacturer's component maintenance manual states that the acceptable limit for webbing fraying was a 6-inch area.
Microscopic examination of the separated fibers revealed that they had separated in overload. The airplane's maintenance manual and a Federal Aviation
Administration advisory circular contained information pertaining to the inspection of shoulder harnesses during 100-hour or annual inspections. The accident
airplane's most recent annual inspection was completed about 1 month before the accident. Although the pilot's toxicology report was positive for pain
medication, the medication was not detected in his blood; thus, it is likely that the pilot took the medication many hours before the accident flight and was not
impaired during the flight. Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's failure to position the
fuel selector handle in a fuel tank detent, which resulted in a total loss of engine power due to fuel starvation. Contributing to the pilot's fatal injuries was the
separation of his shoulder harness due to overload in an area of excessive fraying.
Events
1. Approach - Fuel starvation
2. Approach - Loss of engine power (total)
4. Emergency descent - Collision with terr/obj (non-CFIT)
1. Personnel issues-Task performance-Use of equip/info-(general)-Pilot - C
2. Aircraft-Aircraft systems-Fuel system-Fuel selector/shutoff valve-Incorrect use/operation - C
3. Aircraft-Fluids/misc hardware-Misc hardware-Fasteners-Not specified - F
Narrative
HISTORY OF FLIGHT
On December 18, 2013, about 1110 eastern standard time, a Beech A36TC, N3705Z, was substantially damaged when it impacted terrain near Charlottesville,
Virginia, while on approach to Charlottesville-Albemarle Airport (CHO), Charlottesville, Virginia. The commercial pilot was fatally injured. The flight departed
from Woodbine Municipal Airport (OBI), Woodbine, New Jersey, about 0946, and was destined for CHO. Visual meteorological conditions prevailed and an
instrument flight rules flight plan had been filed. The personnel flight was conducted under the provisions of 14 Code of Federal Regulations Part 91.
Review of air traffic control information, provided by the Federal Aviation Administration (FAA), revealed that the pilot contacted CHO tower at 1104 and
reported that he was 13 miles from CHO at 4,300 feet mean sea level. A CHO tower controller instructed him to enter a left base leg for runway 21 and report 3
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miles out from the airport. At 1108, the pilot declared an emergency. The controller asked for the nature of the emergency and the pilot reported his engine was
"dying." The controller then asked the pilot the number of people onboard and fuel remaining. The pilot replied one person onboard and 2 hours of fuel. The
pilot's last transmission to CHO tower was at 1110 when he stated he was not going to reach the airport.
PILOT INFORMATION
The pilot held a commercial pilot certificate with ratings for airplane single-engine land, airplane multiengine land, and instrument airplane. His most recent FAA
second-class medical certificate was issued on June 20, 2013. At that time, the pilot reported a total flight experience of 2,185 hours; of which, 32 hours were
flown during the previous 6 months. The pilot's most recent logbook was not recovered.
The six-seat, low-wing, retractable tricycle gear airplane, serial number EA-146, was manufactured in 1980. It was powered by a Continental TSIO-520,
300-horsepower engine equipped with a three-blade Hartzell constant-speed propeller. According to the aircraft logbooks, the airplane's most recent annual
inspection was completed on November 23, 2013. At that time, the airplane had accumulated 5,554.6 total hours of operation and the engine had accumulated
863.6 hours since factory rebuilt. The pilot purchased the airplane in 2002.
The 1118 recorded weather observation at CHO, elevation 640 feet, included wind from 230 degrees at 7 knots, visibility 10 miles, sky clear, temperature 4
degrees C, dewpoint minus 8 degrees C, altimeter 30.17 inches of mercury.
WRECKAGE INFORMATION
The accident site was located in front of a residence, about 3 miles east of CHO. The initial impact point was identified by several damaged tree limbs, and a
wreckage path about 200 feet in length, oriented approximately 090 degrees magnetic, extending through the impact area. Browning vegetation was observed
along the wreckage path. Fragments of the airplane, including portions of the outboard right and left wings were located along the wreckage path. The engine
remained attached to the fuselage, and all three propeller blades exhibited postcrash impact damage with minimal leading edge and rotational signature
damage.
The airplane remained upright and the cockpit remained intact, but the pilot's shoulder harness had separated. The harness was forwarded to the NTSB
Materials Laboratory, Washington, D.C., for further examination.
Further review of the cockpit revealed that the fuel selector was found positioned between the left and right tank detents. A placard on the fuel selector stated:
"WARNING POSITION SELECTORS IN DENTENTS ONLY. NO FUEL FLOW TO ENGINES BETWEEN DETENTS." Further examination of the fuel selector
was conducted at a recovery facility, under the supervision of an NTSB investigator, on April 2, 2014. The examination did not reveal any preimpact mechanical
malfunctions with the fuel selector.
The engine was subsequently test-run at the manufacturer's facility on April 8, 2014, under the supervision of an NTSB investigator. The engine started on the
first attempt without hesitation and ran continuously at different power settings, including full power for 5 minutes (for more information, see Engine Operational
Test Report in the NTSB Public Docket).
A JPI EDM-700 engine monitor was recovered from the cockpit and forwarded to the NTSB Vehicle Recorder Laboratory, Washington, D.C. Data were
successfully downloaded from the unit and plotted. Review of the plot revealed that the monitor recorded cylinder head temperatures and exhaust gas
temperatures for each of the six cylinders. The plot also revealed that those temperatures began to drop at 1103:08. The engine monitor did not record fuel
quantity or fuel flow (for more information see Engine Data Monitor and GPS Factual Report in the NTSB Public Docket).
A handheld Garmin GPSMAP 196 was also recovered from the wreckage and forwarded to the NTSB Vehicle Recorder Laboratory, Washington, D.C. Data
were successfully downloaded from the unit and plotted for the entire accident flight. Review of the plot revealed that the last data point was captured at
1110:41, indicating a GPS altitude of 535 feet at a location about 225 feet east of where the main wreckage came to rest.
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MEDICAL AND PATHOLOGICAL INFORMATION
An autopsy was performed on the pilot on December 19, 2013, by the State of Virginia Office of the Chief Medical Examiner, Richmond, Virginia. The cause of
death was noted as "Blunt force trauma of the torso." The report also noted a near-complete transection of the thoracic aorta.
Toxicological testing was performed on the pilot by the FAA Bioaeronautical Science Research Laboratory, Oklahoma City, Oklahoma. Review of the toxicology
report revealed:
"0.068 (ug/mL, ug/g) Dihydrocodeine detected in Urine
Dihydrocodeine NOT detected in Blood
0.883 (ug/ml, ug/g) Hydrocodone detected in Urine
Hydrocodone NOT detected in Blood
0.558 (ug/mL, ug/g) Hydromorphone detected in Urine
Hydromorphone NOT detected in Blood
Ibuprofen detected in Urine
140.1 (ug/ml, ug/g) Salicylate detected in Urine."
TESTS AND RESEARCH
The pilot's shoulder harness was manufactured in November 1979 by Pacific Scientific Company and was subsequently repaired in July 1999 by Safety, LTD.
NTSB Materials Laboratory examination of the shoulder harness revealed that the belt had separated about 31 inches from where the fastener connected to the
lapbelt. That location of the separation corresponded approximately to where the belt would pass through the swivel ring (D-ring) behind the pilot's shoulder.
Additionally, in the area of separation, the belt exhibited about .25-inch fraying on one edge and 1.25-inch fraying on the other edge, along a total area of
approximately 7.75 inches. Review of the shoulder harness manufacturer's component maintenance manual revealed that the acceptable limit for webbing
fraying could not exceed a 6 inch area. Microscopic examination of the separated fibers revealed that they exhibited mushroom filament ends, consistent with
overload (for more information see Materials Laboratory Factual Report in the NTSB Public Docket).
Review of the airplane manufacturer's maintenance manual, for the make and model airplane, "100-Hour Or Annual Inspection.C. Cabin Inspection.15 Seats,
Seat Belts And Shoulder Harnesses" revealed:
"Inspect cabin seats, seat belts and shoulder harnesses for proper operation, condition and security of attachment."
Review of FAA Advisory Circular 43.13-1B, "Acceptable Methods, Techniques, and Practices - Aircraft Inspection and Repair" Chapter 9-46, "Miscellaneous
Equipment" revealed:
"The webbing of safety belts, even when mildew-proofed, is subject to deterioration due to constant use, cleaning, and the effects of aging. Fraying of belts is
an indication of wear, and such belts are likely to be unairworthy because they can no longer hold the minimum required tensile load."
In December, 2013, the NTSB released Safety Alert SA-027, "Check Your Restraints.Carefully follow restraint system maintenance and replacement guidance
to prevent death and injuries."
According to fueling records and GPS data, prior to the accident flight, the airplane flew uneventfully from CHO to OBI on December 1, 2013. At the completion
of that flight, the airplane was completely fueled and not flown again until the accident flight.
Review of the "Before Landing" checklist in the airplane's pilot operating handbook revealed: ".2. Fuel Selector Valve - SELECT TANK MORE NEARLY FULL."
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03/11/2015 1233 CDT Regis# N774TA
Acft Mk/Mdl BEECH B19
Acft SN MB825
Eng Mk/Mdl LYCOMING O-320-E3D
Opr Name: GDS PROPERTIES
Osage Beach, MO
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
0
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: STN
Events
1. Maneuvering - Loss of engine power (total)
Narrative
On March 11, 2015, at 1233 central daylight time, a Beech B19, N774TA, was ditched in Lake Ozark, Osage Beach, Missouri, after oil pressure was lost and
the engine seized. One passenger was seriously injured, but the pilot and another passenger escaped injury. The airplane was substantially damaged. The
airplane was registered to GDS Properties and operated by the pilot, both of St. Charles, Missouri, under the provisions of 14 Code of Federal Regulations Part
91 as a personal flight. Visual meteorological conditions prevailed at the time of the accident, and no flight plan had been filed. The cross-country flight
originated from Grand Glaize-Osage Beach Airport (K15), Osage Beach, Missouri, about 1225, and was en route to Creve Coeur Airport (1H0), St. Louis,
Missouri.
The pilot told a Federal Aviation Administration (FAA) inspector that s everything appeared to be normal when he conducted his preflight inspection. There was
6 quarts of oil on the dipstick and the oil pressure was "in the green" during the engine run-up check. Shortly after takeoff, when the airplane had attained an
altitude of about 2,800 feet, he noticed the oil pressure had dropped to zero. As he was turning back to the airport, the propeller stopped. He ditch in Lake
Ozark. The occupants exited the airplane and were located on the beach.
The FAA inspector verified there was ample fuel on board and blue in color. The throttle linkage was connected. The engine had seized and could not be turned
by hand. The inspector said he could not find the oil dipstick when the airplane was recovered from the lake. The pilot, however, was adamant that he had
replaced the dipstick after checking the oil. The pilot also said he had changed the oil (7 quarts) two days before the accident.
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07/10/2014 1150 EDT Regis# N6222Q
Titusville, FL
Apt: Arthur Dunn Airpark X21
Acft Mk/Mdl BEECH C24R
Acft SN MC-771
Eng Mk/Mdl LYCOMING IO-360-A1B6
Acft TT
Fatal
Opr Name: SOUTHEAST AVIATION SERVICES, INC.
Opr dba:
2835
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Events
1. Enroute-descent - Fuel exhaustion
Narrative
On July 10, 2014, about 1150 eastern daylight time, a Beechcraft C24R, N6222Q, was substantially damaged during a forced landing near Titusville, Florida.
The commercial pilot and the passenger received minor injuries. Visual meteorological conditions prevailed and no flight plan was filed for the local flight that
departed Space Coast Regional Airport (TIX), Titusville, Florida at 1042. The personal flight was conducted under the provisions of Title 14 Code of Federal
Regulations Part 91.
According to written statements by the pilot and passenger, the purpose of the flight was to test some recently serviced avionics and the auto pilot system.
After an uneventful departure, the pilot changed the fuel selector from the left tank to the right tank and flew north along the coast for about 30 minutes. The
pilot then made a 180-degree turn to the south and switched the fuel selector to the left tank. About that time, the pilot momentarily detected an odor of fuel.
His passenger did not smell any fuel, and the pilot reported no abnormal engine indications. After about 30 additional minutes of flight, the pilot descended the
airplane to an altitude about 1,200 feet above ground level, and the engine subsequently experienced a total loss of power. The pilot manipulated the fuel
selector and activated the fuel boost pump, but the engine did not restart. He attempted a forced landing on the roof of an automotive supply store, but the
airplane crashed through the roof and came to rest upright inside the building. The pilot added that prior to the flight, he estimated the fuel quantity by visually
estimating the distance between the top of the fuel and each wing tank tab, which corresponded to a departure with 27 gallons of fuel onboard and he flew for
about 45 minutes on the left wing tank and 23 minutes on the right wing tank before the engine lost all power.
Postaccident examination by a Federal Aviation Administration (FAA) inspector revealed that the airplane had sustained substantial damage to the wings and
empennage. There was also a fuel sump strainer valve on the underside of the fuselage that was observed in the "locked" open position. The strainer valve
was equipped with two "tangs" that extended through a track on the side of the valve. When the tangs were pushed up the valve opened, which allowed fuel to
flow out. When the tangs were release a spring pushed the valve to the closed position. The valve could be "locked" in an open position by pushing the tangs
up and then rotating the valve counter clockwise until the tangs reached the end of the tracks. When the tangs on the sump valve were pushed in and release
on the accident airplane, the valve would spring back to the closed and locked position. The valve remained in the open and locked position when pushed up
and turned counter clockwise. According to the FAA inspector, first responders reported that the fuel tanks were breached and there was no evidence of fuel at
the accident site. The inspector also stated the sump strainer valve was located several inches below the fuselage and, as a result, it was possible that leaking
fuel would fall below and not contact or stain the fuselage.
The airplane was examined and the engine test-run at a secure facility by a FAA inspector, who was assisted by a representative of the airframe manufacturer.
The engine was test run for several minutes with the throttle in the idle setting and ran smoothly and continuously, but was shut down due to the condition of
the engine mounts and induction lines. The examination revealed that the fuel sender, fuel tank gauges and fuel boost pump functioned normally and no leaks
were discovered in any of the fuel lines.
The airplane was manufactured in 1982 and was equipped with an IO-360-A1B6, 200 horsepower, reciprocating engine. The airplane's most recent annual
inspection was completed on March 10, 2014 at a total airframe time of 2,835 hours. The engine had accumulated 908 hours of operation since its most recent
overhaul.
According to the manufacturer's pilot's operating handbook, at a cruise altitude of 5,000 to 6,000 feet, under standard atmospheric conditions, and at a
maximum cruise power, the airplane's estimated fuel consumption was approximately 10.2 gallons per hour. During subsequent testing, a similar airplane was
used to check the flow rate through the strainer drain. Approximately 2 quarts were drained through the strainer drain in 2.3 minutes without the engine running.
Performance calculations indicated that the engine would have burned about 7.5 gallons from the left wing tank and 3.8 gallons from the right wing tank.
Between the airplane's fuel burn and the results from the strainer drain testing, the airplane would have vacated a total of about 28 gallons of fuel in flight.
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09/13/2014 2130 EDT Regis# N6648V
Monroe, GA
Apt: N/a
Acft Mk/Mdl BELLANCA 17-30A
Acft SN 30301
Eng Mk/Mdl CONT MOTOR IO-520
Acft TT
Fatal
Opr Name: BAILEY JASON L
Opr dba:
2969
0
Ser Inj
2
Aircraft Fire: NONE
AW Cert: STN
Summary
During the approach at night, the airplane experienced a total loss of engine power, and the pilot performed a forced landing into trees. Subsequent examination
of the engine revealed that the oil filter adapter was loose and that it was installed incorrectly with two copper crush gaskets rather than with one copper crush
gasket and one fiber gasket per the manufacturer's installation instructions. The fiber gasket would have held the required torque for the fitting; however, the
copper crush gasket did not hold the required torque. Because the oil filter adapter was loose, oil leaked from the engine, which led to the failure of the Nos. 4
and 5 connecting rods due to a lack of oil lubrication. The oil filter adapter was not original equipment on the engine. Although it could be installed under a
supplemental type certificate, a review of maintenance and aircraft records did not reveal any entry or record pertaining to the installation of the oil filter
adapter. The airplane had been operated for about 70 hours since its most recent annual inspection, which was performed about 1 year before the accident. It
could not be determined when the oil filter adapter was incorrectly installed.
Although the pilot stated that he had fueled the airplane with 100 low-lead aviation gasoline, automobile gasoline was recovered from the fuel tanks. The
higher-compression ratio engine was not designed or approved to operate on automobile gasoline, and engine examinations revealed that it had been operating
at higher temperatures due to the use of automobile gasoline. If the engine had not failed due to oil starvation, it is likely that it would have soon begun to
detonate due to the use of the improper fuel.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The improper installation of the
oil filter adapter at an unknown time, which resulted in an oil leak and subsequent oil starvation to the engine.
Events
1. Approach - Loss of engine power (total)
1. Personnel issues-Task performance-Maintenance-Installation-Maintenance personnel - C
2. Aircraft-Aircraft power plant-Engine (reciprocating)-Recip eng oil sys-Incorrect service/maintenance - C
3. Personnel issues-Action/decision-Action-Incorrect action performance-Pilot
4. Aircraft-Fluids/misc hardware-Fluids-Fuel-Fluid type
5. Personnel issues-Task performance-Record-keeping-Aircraft/maintenance logs-Pilot
6. Aircraft-Fluids/misc hardware-Fluids-Oil-Fluid level - C
Narrative
On September 13, 2014, about 2130 eastern daylight time, a Bellanca 17-30A, N6648V, operated by a private individual, was substantially damaged during a
forced landing into trees, following a total loss of engine power during approach near Monroe, Georgia. The private pilot and passenger were seriously injured.
The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Night visual meteorological conditions prevailed for the flight
that departed Dallas Bay Sky Park (1A0), Chattanooga, Tennessee, about 1940. No flight plan was filed for the planned flight to Greene County Airport (3J7),
Greensboro, Georgia.
The pilot reported that prior to the accident flight, he completed a preflight inspection of the airplane, which included adding 100 low-lead aviation gasoline to the
left and right wing fuel tanks. He had anticipated fog at his destination airport and planned for a potential diversion to several alternate airports. He
subsequently diverted to Monroe-Walton County Airport (D73), Monroe, Georgia. About 3 miles from D73, the pilot heard a "bang" as the engine began to run
rough and catch fire. He then pulled the mixture lever back and moved the fuel selector to off. He also dove the airplane until the fire was out. The pilot set up
for a forced landing and attempted to glide to D73, but the airplane impacted trees about 1 mile from the airport.
The four-seat, low-wing, retractable-gear airplane, serial number 30301, was manufactured in 1970. It was powered by Continental Motors IO-520,
300-horsepower engine with a compression ratio of 8.5 to 1. The engine was equipped with a McCauley three-blade, constant-speed propeller. According to the
aircraft logbooks, the airplane's most recent annual inspection was completed on September 21, 2013. At that time, the airplane had accumulated 2,969 total
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hours of operation. The engine had accumulated 1,798 hours since it was remanufactured in 1974. The airplane had flown about 68 hours from the time of the
most recent annual inspection, until the accident. The pilot purchased the airplane on November 20, 2013.
The engine was equipped with an F&M Enterprises Inc. (model C6LC) oil filter adapter. The oil filter adapter was not original equipment, but could be installed
on the engine under Federal Aviation Administration (FAA) Supplemental Type Certificate (STC) number DE09356SC; however, review of the engine logbook
did not reveal any record of the oil filter adapter installation. Further review of FAA airworthiness records for the accident airplane did not reveal any record of
the installation being filed with the FAA. Review of the oil filter adapter manufacturer's installation instructions revealed that one fiber gasket and one copper
crush gasket were to be used in the installation.
Initial examination of the engine revealed a hole near the top front of the case. The wreckage was recovered to a salvage facility for further examination by a
representative from the engine manufacturer, under the supervision of an FAA inspector. The examination revealed that the Nos. 4 and 5 connecting rods had
separated and exhibited heat damage due to a lack of lubrication. Further examination revealed that the oil filter adapter was loose and had been installed
using two copper crush gaskets, rather than one copper crush gasket and one fiber gasket per the installation instructions.
Additionally, automobile gasoline was recovered from the fuel tanks, which was not approved for that model engine. Examination of the Nos. 1 and 2 cylinders
revealed little to no combustion deposits, consistent with higher operating temperatures of automobile gasoline in that engine.
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03/08/2015 1650 CDT Regis# N7698S
Acft Mk/Mdl BELLANCA 8KCAB
Acft SN 262-76
Opr Name: WINSTEAD ROBERT M
Kosciusko, MS
Apt: N/a
Rpt Status: Prelim
Fatal
2
Ser Inj
Opr dba:
0
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: STA
Events
1. Maneuvering-low-alt flying - Loss of control in flight
Narrative
On March 8, 2015, around 1650 central daylight time, N7698S, a Bellanca 8KCAB, single-engine airplane, crashed shortly after it made a low pass over a small
private lake near Kosciuko, Mississippi. The private pilot and the pilot rated passenger were fatally injured. The airplane was registered to and operated by a
private individual. Visual meteorological conditions prevailed and no flight plan was filed for the personal flight that departed the Kosciuko-Attala County Airport
(OSX) at an undetermined time and conducted under the provisions of 14 Code of Federal Regulations Part 91.
Several witnesses observed the airplane flying over a private airstrip that was adjacent to a small lake. The witnesses were on the beach of the lake and the
pilot knew the landowner. According to one witness, he said the airplane initially made a high pass over the airstrip. He then returned, but this time he was a lot
lower and he "buzzed" the lake. The pilot then pulled the airplane straight up to clear a stand of 50-foot-tall pine trees, when it suddenly nosed over and
dropped straight down into the ground on the opposite side of the tree line. The witness said the airplane and engine were operating normally and the pilot was
"just having fun." When the airplane passed over the lake, the pilot was grinning from "ear to ear" and the passenger was waving out of the window. The
witness said it wasn't windy or raining at the time of the accident.
Another witness was a retired airline pilot and active aerobatic pilot on the airshow circuit. He owned the land the airplane had flown over and knew the pilot
well. The witness said the pilot flew over the lake on a south-westerly heading but did not recall the airplane's altitude. He could see the pilot in the cockpit and
he was smiling. The airplane then began a climbing right turn. As the airplane turned through a 90-degrees, the left wing dropped. The witness said the pilot
tried to recover from the "cross-control stall", by lowering the nose of the airplane and making a full deflection of the rudder control. The airplane leveled out
momentarily before it suddenly nosed-over. At the same time, the witness heard the engine power go to full throttle before it impacted the ground. The witness
said the airplane did not have the altitude to recover and did not rotate before it hit the ground.
A postaccident examination of the airplane was conducted the day after the accident. The airplane was pointed nose down with the tail almost vertical in the
air. The engine was partially buried in the soft ground about 1-2 feet. Both wings exhibited leading edge impact damage, and the wood spars and ribs were
fractured. Flight control continuity was established for the ailerons to the wing root. The cockpit area was crushed. The empennage and tail section were intact.
The outboard section of the left horizontal stabilizer exhibited minor damage. Flight control continuity for the elevators and rudder was established to the aft
cockpit area.
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08/28/2014 2303 EDT Regis# N1741Q
Creedmoor, NC
Apt: N/a
Acft Mk/Mdl CESSNA 150L
Acft SN 15073041
Eng Mk/Mdl CONT MOTOR O-200
Acft TT
Fatal
Opr Name: LEGGETT JAMES W
Opr dba:
4878
0
Ser Inj
1
Aircraft Fire: NONE
AW Cert: STN
Events
1. Enroute-cruise - Fuel exhaustion
Narrative
On August 28, 2014, at 2303 eastern daylight time, a Cessna 150L, N1741Q, operated by a private individual, was substantially damaged during a forced
landing, following a total loss of engine power during cruise flight near Creedmoor, North Carolina. The airline transport pilot was seriously injured. The personal
flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Night visual meteorological conditions prevailed for the flight that departed
Bowman Field (LOU), Louisville, Kentucky, about 1811. No flight plan was filed for the planned flight to Elizabeth City Regional Airport (ECG), Elizabeth City,
North Carolina.
According to the pilot's written statement, he completed his flight planning in accordance with Federal Aviation Regulation minimum fuel requirements and
completely fueled the airplane prior to departure. The pilot added that while enroute, he had to climb above 12,500 feet mean sea level to remain clear of visible
moisture. He further stated that with favorable winds, he could have flown to Rocky Mount Regional Airport (RWI), Rocky Mount, North Carolina, but elected to
divert due to physiological needs, to Raleigh-Durham International Airport (RDU), Raleigh/Durham, North Carolina. About 13 miles from RDU, as the pilot
reduced engine power, the engine began to run rough. The pilot thought the roughness was due to a magneto or valve issue as each fuel gauge indicated more
than "1/4" full. The engine then lost all power when the airplane was 7 to 10 miles from RDU. The pilot attempted to restart the engine with no success and
subsequently performed a landing to a dark area. The airplane impacted trees and although dizzy from the impact, the pilot was able to egress. He further
stated that law enforcement located him about 2 hours later and someone remarked that the airplane was leaking fuel.
According to data from the Federal Aviation Administration (FAA), the pilot contacted LOU Ground Control at 1803 and requested flight following to RWI at
13,500 feet. The controller asked the pilot to verify the altitude, which he did. At 1814, while in contact with LOU Departure Control, the pilot changed his
destination from RWI to ECG. The pilot subsequently queried several controllers about wind information at altitudes and at 1859, reported climbing through
12,200 for 13,500 feet. At 1908, he requested to climb from 13,500 to 15,500 feet. The Indianapolis Center controller replied that the altitude was at the pilot's
discretion. At 1940, the pilot reported that he was climbing through 14,000 feet for 17,500 feet. The Indianapolis Center controller replied that the altitude was at
the pilot's discretion. At 2030, the controller queried the pilot why he was trying to climb to 17,500 feet in a Cessna 150. The pilot replied that he had
supplemental oxygen and that altitude would result in a good fuel burn and endurance.
At 2036, the pilot contacted Atlanta Center and reported that he was climbing through 15,200 feet for 17,500 feet. At 2046, the pilot requested to descend to
14,500 feet to perform some data collection, which was approved by the Atlanta Center controller. At 2113, the pilot contacted Washington Center and advised
he was at 14,500 feet. At 2130, the pilot to descended to 11,500 feet. At 2124, the Washington Center controller asked the pilot if he was going to ECG. The
pilot replied affirmative, but that he may have to divert to RDU for fuel. At 2152, the pilot cancelled flight following and reported that he was diverting to Danville
Regional Airport (DAN), Danville, Virginia for fuel.
Review of radar data revealed that the airplane did not land at DAN or another airport for fuel. At 2256, the pilot contacted RDU Approach Control. The pilot
stated he was approximately 15 miles north of RDU with a magneto problem and requested an immediate turn to the airport. The controller then provided the
wind, altimeter information, and a vector of 230 degrees to the airport. At 2259, the pilot reported that the engine "just quit." The controller also provided
information about a highway 5 miles east of the airplane and the pilot requested that the controller keep the airplane away from populated areas. The controller
then advised that there was a lake about 3 to 4 miles to the pilot's right and the pilot requested vectors toward the lake, which the controller provided; however,
the airplane impacted trees in a cul-de-sac about 3 miles east of the lake.
The airplane came to rest in the front yard of a residence, partially suspended in a tree. Further review of radar and communication data revealed that at the
time of the accident, the airplane had been flying for 4 hours, 52 minutes. It had remained above 12,500 feet for about 2 hours, 40 minutes, reaching a
maximum altitude of 16,000 feet. According to written statements from three North Carolina Highway Patrol troopers, the wreckage was located about 2 hours
after the accident. All three troopers noted a strong odor of alcohol on the pilot's breath and that his eyes were red and glassy. One trooper obtained a breath
sample from the pilot, which recorded a .16 on the portable breathalyzer test.
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Examination of the wreckage by an FAA inspector revealed that the fuel tanks were not compromised and there was no odor of fuel at the accident site. He
observed that there was no fuel in the right wing fuel tank, a trace amount of fuel in the left wing fuel tank, and only 2 to 3 ounces of fuel in the fuel sump. The
inspector did not observe any preimpact mechanical malfunctions. He also did not observe any supplemental oxygen onboard. The wreckage was recovered to
a salvage facility for further examination by representatives from the airframe and engine manufacturer, under the supervision of an FAA inspector. When fuel
was added to the carburetor, the engine started after several attempts. Due to vibration as a result of impact damage, the engine was shut down after running 5
to 10 seconds. The airframe was examined and fuel gauges tested, with no anomalies noted.
Review of a Cessna 150 Owner's Manual revealed that the published service ceiling for the airplane was 12,600 feet. Further review of the manual revealed
that at 12,500 feet, with a lean mixture and rpm at 2,500, the airplane had an endurance of 5.8 hours; however, those calculations did not include fuel
consumed for taxi, takeoff, climb, and a continued climb attempt to 17,500 feet.
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Accident Rpt# WPR13FA118
02/08/2013 930 MST
Regis# N89059
Tucson, AZ
Acft Mk/Mdl CESSNA 152
Acft SN 15282614
Acft TT
Fatal
Opr Name: ARIZONA AERO-TECH
Opr dba:
8037
1
Apt: Ryan Field RYN
Ser Inj
0
Aircraft Fire: NONE
Events
1. Prior to flight - Miscellaneous/other
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.
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.
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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.
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.
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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.
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
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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.
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
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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
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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03/03/2015 1100 EST Regis# N498TC
Acft SN 15283390
Eng Mk/Mdl LYCOMING 0-235 SERIES
Opr Name: FLORIDA FLIGHT TRAINING CENTER
Sarasota, FL
Apt: N/a
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
0
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: STN
Events
Narrative
On March 3, 2015, about 1100 eastern standard time, a Cessna 152, N498TC, was substantially damaged during a forced landing following a total loss of
engine power near Venice, Florida. The flight instructor (CFI) was not injured, and the student pilot sustained minor injuries. Visual meteorological conditions
prevailed, and no flight plan was filed for the local instructional flight, which departed Venice Municipal Airport (VNC), Venice, Florida. The flight was conducted
under the provisions of Title 14 Code of Federal Regulations Part 91.
In a written statement to the Federal Aviation Administration, the CFI indicated that, after completing maneuvers at 2,000 feet, he initiated a simulated engine
failure. He selected a field as a forced landing location, and carburetor heat was applied. After turning onto final approach for the selected field at an altitude of
about 500 feet, the CFI turned off the carburetor heat and applied engine power to end the simulation and initiate a climb. The engine "sputtered and produced
no power," and the CFI conducted a forced landing to the field. Upon touchdown, the left wing contacted the ground and the airplane "cartwheeled." The
airplane came to rest upright, and the CFI and student subsequently egressed.
Postaccident examination of the airplane by a Federal Aviation Administration inspector revealed substantial damage to both wings and the forward fuselage.
There was no fuel observed in either of the airplane's two wing fuel tanks; however, fuel quantity at the time of the accident could not be determined as a fuel
line was damaged during impact. The airplane was subsequently removed from the site, the starter was replaced, and an auxiliary fuel supply was plumbed into
the airplane's fuel system. The engine started immediately, accelerated smoothly, and ran continuously without interruption and with no anomalies observed.
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10/05/2013 1600 EDT Regis# N8715U
Gainesville, FL
Apt: N/a
Acft Mk/Mdl CESSNA 172 - F-F
Acft SN 17252619
Eng Mk/Mdl LYCOMING O-360
Acft TT
Fatal
Opr Name: BEACH BANNERS INC
Opr dba:
4989
0
Ser Inj
0
Aircraft Fire: NONE
Summary
The pilot reported that, about 20 minutes into the banner tow flight, he noticed that the airplane had descended about 100 ft from its established altitude. He
responded by increasing engine power and enriching the mixture while observing that the oil temperature gauge was indicating "hotter than normal." The
airplane continued to descend, the oil temperature continued to rise into the red arc, and the engine subsequently experienced a total loss of power. The pilot
released the banner and then unsuccessfully attempted to restart the engine. He then conducted a forced landing to a nearby field. The airplane impacted a
parked vehicle, which resulted in substantial damage to the fuselage and both wings. Postaccident engine examinations revealed no mechanical malfunctions
or failures, and a test run was conducted using the fuel onboard at the time of the accident with no anomalies observed.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: A total loss of engine power for
reasons that could not be determined because a postaccident engine examination and test run revealed no anomalies.
Events
1. Maneuvering-low-alt flying - Loss of engine power (total)
2. Environmental issues-Physical environment-Object/animal/substance-Ground vehicle-Contributed to outcome
Narrative
On October 5, 2013, about 1600 eastern daylight time, a Cessna 172F, N8715U, was substantially damaged during a forced landing following a total loss of
engine power near Gainesville, Florida. The commercial pilot and pilot-rated passenger sustained minor injuries. The local banner tow flight departed
Gainesville Regional Airport (GNV) about 1540. Visual meteorological conditions prevailed, and no flight plan was filed for the flight, which was conducted under
the provisions of Title 14 Code of Federal Regulations Part 91.
The pilot stated that a preflight inspection of the airplane revealed no anomalies, and he subsequently departed on the flight and performed the banner pick-up.
He proceeded toward the stadium around which he was to tow the banner, leveled the airplane at 1,200 feet above ground level (AGL), reduced engine power
to 2,250 rpm, and leaned the mixture. He then extended the wing flaps to 10 degrees, and slowed the airplane to 50 mph. About 20 minutes into the flight, the
pilot noticed that the airplane had descended about 100 feet, and he responded by increasing engine power and enriching the mixture, while observing that the
oil temperature gauge indicated "hotter than normal." The airplane continued to descend and the oil temperature continued to rise into the red arc, and the
engine subsequently experienced a total loss of power. The pilot released the banner, attempted to restart the engine to no avail, and then conducted a forced
landing to a nearby field. He stated that due to "excessive airspeed" upon touchdown, the airplane bounced and impacted a parked truck, resulting in
substantial damage to the fuselage and both wings.
The pilot held a commercial pilot certificate with ratings for airplane single- and multi-engine land, as well as an instrument rating; and flight instructor certificate
with ratings for airplane single- and multi-engine, and instrument airplane. His most recent first-class Federal Aviation Administration (FAA) medical certificate
was issued in September 2013. Following the accident, he reported 2,513 total hours of flight experience, of which 1,402 hours were in the accident airplane
make and model.
The airplane was manufactured in 1965, and was equipped with a Lycoming O-360-A1A, 200 hp, reciprocating engine. Its most recent annual inspection was
completed July 24, 2013. At the time of the accident, the airplane had accumulated 4,989 total hours of operation. According to the operator, the airplane was
being operated on automotive fuel. Review of the airplane's airworthiness records showed that no supplemental type certificate had been issued authorizing the
use of automotive fuels.
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Following the accident, the airplane was removed from the site and subsequently examined by an FAA inspector. The engine exhibited little impact damage.
The carburetor remained attached; however, the carburetor heat cable was disconnected and hanging free from the firewall. The magnetos remained attached
and undamaged. The engine contained 7 quarts of oil. The oil filter was removed and opened, with no anomalies observed. The spark plugs were removed and
appeared "blackish" in color. The electric fuel pump and starter were replaced, and the engine was secured for a test run. Utilizing the fuel onboard at the time
of the accident, the engine started and ran for several minutes with no anomalies observed.
A fuel sample was taken from the carburetor prior to the test run, and sent for analysis at an aviation fuel testing laboratory. According to the laboratory, a Karl
Fisher water test revealed "high" water content, and a microbial test was negative for bacteria and fungus. The quantity of the sample provided was insufficient
to conduct distillation and flash point tests; therefore it could not be determined if the sample contained ethanol.
The 1553 recorded weather at GNV, 5 miles southwest of the accident site included wind from 090 degrees at 6 knots, 10 miles visibility, sky clear,
temperature 31 degrees C, dew point 19 degrees C, and a barometric altimeter setting of 30.00 inches of mercury. Review of an FAA carburetor icing
probability chart revealed the potential for serious icing at glide power given the atmospheric conditions present about the time of the accident.
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03/15/2015 1134 EDT Regis# N8452X
Acft Mk/Mdl CESSNA 172C
Acft SN 17248952
Eng Mk/Mdl CONT MOTOR 0-300 SER
Opr Name: R A MARSH FLYING CLUB LLC
Williamson, GA
Apt: Peach State Airport GA2
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
0
Prob Caus: Pending
Aircraft Fire: UNK
AW Cert: STN
Events
1. Landing-flare/touchdown - Landing gear collapse
Narrative
On March 15, 2015, at 1134 eastern daylight time, N8452X, a Cessna 172C, sustained substantial damage during landing roll-out at the Peach State Airport
(GA2), Williamson, Georgia. The airline transport rated pilot sustained minor injuries and the passenger was not injured. The airplane was registered to and
operated by the R A Marsh Flying Club, Williamson, Georgia. No flight plan was filed for the local flight that departed about 1020. Visual meteorological
conditions prevailed for the personal flight conducted under 14 Code of Federal Regulations Part 91.
In a written statement, the pilot stated that he was making a soft field landing to a grass runway. The initial touchdown was on the main wheels with a nose up
attitude. As the airplane decelerated, the pilot lowered the nose wheel. He said that immediately after the nose wheel touched down a "significant" nose
shimmy was felt. The pilot thought the nose wheels' shimmy damper had failed, so he applied back pressure on the control wheel to minimize weight on the
nose wheel. As the airplane continued to decelerate, the pilot again lowered the nose and a more substantial vibration occurred and he again raised the nose
wheel as much as possible but eventually so much groundspeed had depleted that he could no longer hold the nose off the ground. When the nose wheel
touched down on the ground for the last time, it completely failed and separated. The nose of the airplane then dropped to the ground and the airplane slid to a
stop.
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03/18/2014 1925 EDT Regis# N46603
Elizabethton, TN
Apt: Elizabethton Muni 0A9
Acft Mk/Mdl CESSNA 172K
Acft SN 17257379
Eng Mk/Mdl LYCOMING O-320-E2D
Acft TT
Fatal
Opr Name: SKYPARK INC
Opr dba:
6688
0
Ser Inj
0
Aircraft Fire: NONE
Summary
The pilot and two passengers were returning home on a cross-country flight. The pilot departed on the accident flight from runway 06 on the left downwind leg
with the intention of flying over a mountain range; the airport facility directory current at the time of the accident stated that departures from runway 06 were
required to make right traffic, which is intended to provide departing aircraft with adequate clearance from the surrounding terrain. During the climb, the pilot
became concerned that the airplane would not clear the approaching rising terrain, so he attempted to maneuver the airplane away from it; however, the
airplane subsequently impacted trees and terrain. Examination of the wreckage revealed no preexisting mechanical anomalies with the airplane that would have
precluded normal operation. The pilot did not calculate the performance requirements needed to clear the 3,000-ft-tall mountain peak before the flight.
Performance calculations based on data reported by the pilot indicated that the airplane's climb rate was too low to provide clearance from terrain along the
pilot's selected route.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's delayed decision to
maneuver around rising terrain, which resulted in a collision with trees and terrain. Contributing to the accident was the pilot's failure to calculate the
performance requirements needed to climb over mountainous terrain before the flight.
Events
1. Enroute-climb to cruise - Controlled flight into terr/obj (CFIT)
1. Personnel issues-Action/decision-Info processing/decision-Decision making/judgment-Pilot - C
2. Environmental issues-Physical environment-Terrain-Mountainous/hilly terrain-Contributed to outcome
3. Personnel issues-Task performance-Planning/preparation-Flight planning/navigation-Pilot - F
5. Personnel issues-Action/decision-Action-Incorrect action performance-Pilot - C
Narrative
HISTORY OF FLIGHT
On March 18, 2014, about 1930 eastern daylight time, a Cessna 172K airplane, N46603, was substantially damaged after it impacted mountainous terrain in
Elizabethton Municipal Airport (0A9), Elizabethton, Tennessee. The private pilot and a passenger sustained serious injuries and another passenger received
minor injuries. Visual meteorological conditions prevailed and no flight plan was filed for the flight, which originated from 0A9 about 1915 and was destined for
Weltzien Skypark (15G), Wadsworth, OH. The personal flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91.
According to the pilot, he departed 15G three days prior to the accident to fly a family friend to South Carolina. The pilot originally intended to return to 15G the
following day, but was delayed due to weather. On the day of the accident, the pilot and his passengers left South Carolina bound for 15G. The pilot made an
unscheduled stop for fuel at 0A9, after discovering the fuel services at his intended airport were closed. After refueling at 0A9 he departed runway 06 and flew
the airport traffic pattern. He maintained an altitude of 500 feet above ground level (agl) and exited the traffic pattern on the left downwind leg on a course direct
towards Holston Mountain. The pilot followed the upslope of the mountain at a 500 feet per minute rate of climb. Concerned that the airplane would not clear
the approaching terrain, the pilot decided to turn the airplane towards a small valley to his right that appeared to have a lower terrain elevation. During the turn
the airplane descended, impacted trees and then terrain before coming to rest.
During the pilot's interview with a Federal Aviation Administration (FAA) inspector and the NTSB investigator-in-charge, the pilot stated he should have "gained
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more altitude" before starting his climb over the mountain. In an interview with an FAA inspector the pilot was asked if he had any mechanical issues with the
aircraft, to which the pilot replied "No."
According to the pilot and FAA records, he held a private pilot certificate for airplane single-engine land. The pilot's most recent third-class medical certificate
was issued on May 4, 2013. The pilot reported 90 hours of total flight experience, of which 10 hours were in the accident airplane make and model.
AIRPLANE INFORMATION
The airplane was manufactured in 1968 and was equipped with a Lycoming O-320-E2D, 150-hp, carbureted reciprocating engine. According to maintenance
records, the airplane's most recent 100-hour inspection was completed on November 20, 2013. The airplane's most recent engine overhaul was completed on
September 9, 2007. At the time of the accident, the engine had accumulated 6,688 hours of total time in service, and 61 hours of time in service since the most
recent inspection.
The 1856 recorded weather at 0A9, located about 3 nautical miles south of the accident site, included calm wind, clear skies, 10 miles visibility, temperature 13
degrees C, dewpoint 4 degrees C, and an altimeter setting of 29.95 inches of mercury.
According to information provided by the FAA and the airframe manufacturer, the airplane came to rest on its left side about 3000 feet above mean sea level
(msl) in a wooded area and was oriented on a 221 degree heading, the debris path was oriented on a 141 degree heading. All major components of the airplane
were accounted for at the accident site. A section of the fuselage was bent downward and partially separated just aft of the main cabin. The vertical stabilizer
and left horizontal stabilizer remained attached to the empennage, which was co-located with the main wreckage. The right horizontal stabilizer was located
about 200 ft. from the main wreckage with the elevator attached. Both wings remained attached to the fuselage and sustained leading edge crush damage
along their entire length. The right wing was bent in the positive direction about 45 degrees. Both propeller blades remained attached to the hub. One blade
exhibited S-bending with some polishing and chordwise scratching. The outboard section of another propeller blade was bent and the tip was fractured and
separated.
The airframe was examined at the accident site by a representative of the airframe manufacturer under the supervision of a FAA inspector. Control continuity
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was traced from the cockpit area to each of the flight control surfaces. The flap actuator measured 0 degrees, which was consistent with a flaps retracted
positon.
The engine was recovered to a secure facility in Springfield, Tennessee and a follow-up engine examination took place on May 5, 2014 and supervised by a
NTSB investigator. Continuity of the engine's crankshaft and valvetrain were confirmed through rotation at the vacuum pump drive pad, and thumb compression
was confirmed on all cylinders. The top and bottom spark plugs were removed and inspected; the top plugs and two of the bottom plugs exhibited normal wear
and two of the bottom plugs were oil soaked. Both magnetos rotated freely by hand and exhibited normal sparking on all leads.
The fuel strainer contained fuel and the strainer screen was free of debris. The carburetor fuel inlet screen was free of debris and no fuel stains were present on
the carburetor surfaces.
AIRPORT INFORMATION
The single asphalt runway at 0A9 was 4529 feet long by 70 feet wide and was configured in a 6/24 orientation at an elevation of 1593 feet msl. A parallel
taxiway spanning the full length of the runway was present on the west side of the runway. The airport was not served by a local air traffic control tower.
According to the FAA Airport/Facility Directory, effective February 6, 2014 to April 3, 2014, departures from runway 06 were required to make right traffic.
Airplane Performance
The distance between the airport pattern and the top of the mountain is about 1.8 nautical miles (nm) and the elevation at the top of the mountain is about
3,000 feet msl. Based on the values reported by the pilot, at 78 knots the airplane would have travelled to the top of the mountain, 1.8nm, in 1 minute 23
seconds; however, at a 500 feet per minute climb rate, the airplane required 1 minute 48 seconds of flight time to reach the 3,000 foot mountain peak. Density
altitude at the airport around the time of departure was about 1,800 feet.
Research
According to the FAA publication "Tips on Mountain Flying"(FAA-P-8740-60, AFS-803), "a normally aspirated engine will lose 3% of its power per thousand feet
of density altitude increase. Next, as density altitude increases, the wings have less dense air which to create lift. Since a propeller is an airfoil, it, too, will be
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less efficient." The FAA also recommends that pilots cross mountain passes at an altitude at least 1000 feet above the pass elevation.
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01/16/2015 1300 EST Regis# N7079Q
New Castle, PA
Apt: New Castle Airport KUCP
Acft Mk/Mdl CESSNA 172L-H
Acft SN 17260379
Acft TT
Fatal
Opr Name: WEINZIERL RICHARD J
Opr dba:
5040
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Events
Narrative
According to the pilot, he landed the airplane on the centerline of the runway and the airplane began to veer to the left. He applied right rudder pressure;
however, the airplane continued to the left. It traveled off the left side of the runway and came to rest inverted in a ditch, which resulted in substantial damage
to the fuselage and right wing. The pilot indicated that the left brake "locked up" during the accident sequence. A postaccident examination of the airplane
revealed that there were no malfunctions or anomalies with the brake system that would have precluded normal operation prior to the accident.
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01/05/2015 1535 EST Regis# N6591H
Marquette, MI
Apt: Sawyer Intl SAW
Acft SN 17265501
Acft TT
Fatal
Opr Name: MARQUETTE COUNTY FLYING CLUB
INC
Opr dba:
10631
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Events
1. Takeoff - Loss of control on ground
Narrative
The pilot planned a local afternoon flight, which included takeoff from a runway covered with patchy snow and ice. Throughout the morning and afternoon prior
to the accident, surface wind observations were westerly at 5 to 12 knots.
During takeoff roll on the northerly runway, the pilot stated he encountered a gust of westerly crosswinds and the airplane yawed to the left. Unable to maintain
directional control, the pilot aborted the takeoff. The airplane subsequently impacted a snowdrift on the left side of the runway and came to rest inverted. The
airplane sustained substantial damage to both wings. The pilot reported no mechanical malfunctions with the airplane that would have precluded normal
operation.
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09/19/2014 1100 EDT Regis# N13394
Leesburg, FL
Apt: Leesburg International LEE
Acft SN 17262725
Acft TT
Fatal
5848
0
Ser Inj
Opr Name: APOPKA AVIATION & FLIGHT SERVICES Opr dba:
0
Aircraft Fire: NONE
AW Cert: STN
Summary
The flight instructor and student pilot were conducting practice touch-and-go takeoffs and landings in the airport traffic pattern. The instructor stated that the
runway was wet from rain earlier in the day. During the fifth landing, the student landed the airplane right of the runway centerline. The flight instructor described
the landing as "soft" and "slow." The student applied left rudder to steer the airplane back toward the centerline, but the airplane continued to drift left. The flight
instructor stated that he took the flight controls, applied left rudder, and then applied left brake, but the airplane "did not respond." The airplane subsequently
ran off the left side of the runway, impacted a sign, and came to rest upright about 250 ft past the runway edge. The left main landing gear collapsed, and the
firewall sustained substantial damage. Postaccident examination of the landing gear, wheels, brakes, rudder controls, and nosewheel steering revealed no
anomalies.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The flight instructor's delayed
remedial action and his subsequent loss of directional control during landing on a wet runway for reasons that could not be determined because postaccident
examination of the airplane revealed no anomalies.
Events
2. Personnel issues-Task performance-Use of equip/info-Aircraft control-Instructor/check pilot - C
4. Environmental issues-Physical environment-Runway/land/takeoff/taxi surface-Wet-Not specified
5. Personnel issues-Action/decision-Action-Delayed action-Instructor/check pilot - C
Narrative
On September 19, 2014, about 1100 eastern daylight time, a Cessna 172M, N13394, was substantially damaged during a runway excursion while landing at
Leesburg International Airport (LEE), Leesburg, Florida. The flight instructor (CFI) and student pilot were not injured. Visual meteorological conditions prevailed,
and no flight plan was filed for the local instructional flight, which was operated under the provisions of Title 14 Code of Federal Regulations Part 91.
The CFI and student were conducting touch-and-go landings in the airport traffic pattern. During the fifth landing of the day, the student pilot landed right of the
runway centerline. The CFI described the landing as "soft" and stated that the airplane's speed at touchdown was "slow." The student applied left rudder to
steer the airplane back to the runway centerline; however, it continued to drift left. The CFI assumed control of the airplane and applied right rudder, which he
said "had no effect," then applied right brake. He stated that the airplane "did not respond," and continued off the left side of the runway, where it impacted a
sign and eventually came to rest upright in the grass. The CFI stated that it had rained earlier in the day, and the runway was wet at the time of the accident.
The airplane was examined after the accident by a Federal Aviation Administration (FAA) inspector. According to the inspector, the left main landing gear had
collapsed aft, and the left portion of the horizontal stabilizer and elevator were substantially damaged. There were no tire skid marks observed on the runway;
however, tire tracks were evident in the grass leading from the runway to where the airplane came to rest, for a distance of about 250 feet. Examination of the
landing gear revealed that all three tires were inflated properly, and turned freely when rotated. Rudder control system continuity was established from the
cockpit to the rudder, with no anomalies noted. Examination of the nose landing gear revealed that both steering rods remained attached to the nose wheel
yoke. Examination of the brakes revealed no anomalies.
The CFI held a commercial pilot certificate with ratings for airplane single- and multi-engine land, rotorcraft-helicopter, and instrument airplane and helicopter;
and a flight instructor certificate with a rating for airplane single-engine. His most recent FAA first class medical certificate was issued in May, 2011. He
reported 413 total hours of flight experience, of which 120 hours were in the accident airplane make and model.
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The airplane was manufactured in 1973, and had accumulated 5,848.2 total hours at the time of its most recent 100-hour inspection on July 23, 2014.
The 1053 weather observation at LEE included wind from 60 degrees at 5 knots, an overcast cloud layer at 11,000 feet, temperature 27 degrees C, dew point
23 degrees C, and an altimeter setting of 30.01 inches of mercury.
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02/14/2014 1759 CST Regis# N194EX
Pinson, TN
Apt: N/a
Acft SN 17266200
Acft TT
Fatal
Opr Name: BILLY J. LYONS
Opr dba:
2702
0
Ser Inj
1
Aircraft Fire: NONE
AW Cert: STN
Events
3. Landing-flare/touchdown - Hard landing
Narrative
On February 14, 2014, at 1759 central standard time, a Cessna 172M, N194EX, was substantially damaged during a precautionary landing in Pinson,
Tennessee. The private pilot/owner was not injured, and the passenger sustained serious injuries. Night instrument meteorological conditions (IMC) prevailed,
and no flight plan was filed for the personal flight, which was operated under the provisions of Title 14 Code of Federal Regulations Part 91. The airplane
departed Springfield-Branson National Airport, Springfield (SGF), Missouri, with Northwest Alabama Regional Airport (MSL) as the intended destination.
The pilot stated that he obtained "all available" current and forecast weather information along the intended route of flight using a commercial weather vendor,
and updated his weather information during the flight with air traffic control (ATC) and an on-line commercial weather vendor. The weather conditions at
departure were "marginal" visual flight rules (VFR) conditions, and after climbing the airplane to his desired cruising altitude, he was forced to descend due to
worsening weather conditions and to maintain VFR.
The pilot was advised by ATC that the weather at his intended destination had deteriorated, and provided vectors to a suggested diversionary airport. The pilot
turned the airplane to the suggested heading, but continued to descend to maintain VFR. The pilot determined that visual flight could not be continued, and
selected a field for a precautionary landing. The airplane subsequently landed hard in muddy terrain, which fractured the empennage and resulted in substantial
damage to the right wing.
The pilot held a private pilot certificate with a rating for airplane single-engine land. He did not hold an instrument rating. His most recent Federal Aviation
Administration (FAA) third class medical certificate was issued February 2013. The pilot reported 150 total hours of flight experience, of which all 150 hours
were in the accident airplane make and model.
The airplane was manufactured in 1975 and its most recent annual inspection was completed on April 4, 2013, at 2,702 total aircraft hours.
The weather reported at McKellar-Sipes Regional Airport (MKL), Jackson, Tennessee, 13 miles north of the accident site, included an overcast ceiling at 1,300
feet with 3 miles visibility in fog.
The airplane was recovered from the scene and moved to a recovery facility in Springfield, Tennessee, where postaccident examination was conducted under
the supervision of an FAA inspector. The examination revealed there were no preimpact mechanical anomalies that would have precluded normal operation.
The pilot seat remained partially attached to its seat tracks with the adjustment pins engaged. The copilot seat was separated from its tracks, and the seat leg
"ears" were either splayed open or fractured due to overstress.
The seat rails and tracks for both front pilot and copilot seats were inspected for wear in accordance with FAA Airworthiness Directive (AD) Note 11-10-09.
Examination and measurement of the dimensions of the seat rails and tracks revealed that they were worn, but did not exceed the allowable tolerances
specified in the AD.
According to the passenger, she unfastened her seat belt and shoulder harness during the flight to "retrieve a fallen article on the floor of the cockpit." She did
not recall if she refastened the seatbelt and shoulder harness.
Under the "RECOMMENDATION (How could this accident have been prevented?)" section of the NTSB accident report form, the pilot/owner offered the
following:
1. More emphasis was needed on the changing nature of weather conditions, especially on longer leg lengths.
2. The pilot also could have better monitored passenger seatbelt use, especially in low light conditions.
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Accident Rpt# WPR14LA147
03/26/2014 1743 LCL Regis# N9551L
Inarajan, GU
Apt: N/a
Acft Mk/Mdl CESSNA 172P
Acft SN 17276576
Acft TT
Fatal
Opr Name: TREND VECTOR AVIATION INT
Opr dba:
18766
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Summary
The pilot was performing an introductory flight lesson for a prospective student pilot and a passenger. The pilot reported that, about 20 minutes after takeoff,
while in cruise flight, the engine began producing only partial power. The pilot performed troubleshooting steps, including applying carburetor heat, but the
engine did not respond and subsequently lost total power. He performed a forced landing into a field of tall grass. The airplane came to rest nose down after the
nose gear dug into the ground, which resulted in substantial damage. A postaccident examination of the engine and airframe revealed no evidence of
mechanical malfunctions or failures that would have precluded normal operation. The operator's mechanic reported that the airplane's fuel tank vent line was
partially blocked; however, the airplane was equipped with a secondary vented fuel cap, so it is unlikely that fuel starvation occurred.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: A total loss of engine power
during cruise flight for reasons that could not be determined because postaccident examination did not reveal any anomalies that would have precluded normal
operation.
Events
2. Landing - Off-field or emergency landing
3. Landing - Collision with terr/obj (non-CFIT)
2. Environmental issues-Physical environment-Runway/land/takeoff/taxi surface-Soft-Contributed to outcome
Narrative
HISTORY OF FLIGHT
On March 26, 2014, at 1743 local time, a Cessna 172P, N9551L, landed in a field following a loss of engine power near Inarajan, Guam. The airplane was
registered to, and operated by, Trend Vector Aviation International, under the provisions of 14 Code of Federal Regulations Part 91 as an introductory flight
lesson. The flight instructor (CFI) and two passengers were not injured. The airplane sustained substantial damage to the forward fuselage and left wing during
the accident sequence. The local flight departed Guam International Airport, Barrigada, Guam, about 1725. Visual meteorological conditions prevailed, and no
flight plan had been filed.
The CFI reported that after takeoff he initiated a left turn, and having reached an altitude of 1,500 feet mean sea level (msl), he began a turn to the southwest
towards Apra Harbor. He continued the flight while maintaining an altitude of about 1,500 feet msl, an airspeed of between 95 and 100 knots indicated, and an
engine speed of 2,300 rpm. About 20 minutes after takeoff the engine speed began to decrease. He confirmed the mixture control was set to full rich, and then
applied full forward throttle control. The engine speed increased momentarily, but then decreased such that only partial power was being produced. He then
applied full carburetor heat, but the engine did not respond.
The airplane would not maintain altitude, so the pilot initiated an approach to a landfill for a forced landing. As he approached the landing area he could see
heavy equipment on the intended landing zone, so he turned the airplane towards a tall-grass field for a tailwind landing. He stated that during the final
approach the engine was no longer producing any power, and the propeller appeared to be wind-milling. The airplane came to rest nose-down after the nose
gear dug into the ground.
Maintenance records revealed that the airplane had undergone an annual inspection that was completed on January 30, 2014. At that time the airframe had
accrued a total of 18,766.1 flight hours since manufacture in 1986, with the engine accruing 2,360 hours since overhaul. The airplane flew for 90 hours between
the annual inspection and the accident.
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The closest aviation weather observation station was located at Guam International Airport, which was 14 miles north-northwest of the accident site. An
aviation routine weather report was recorded at 1754. It reported: wind from 070 degrees at 13 knots gusting to 20 knots; visibility 10 miles with clear skies;
temperature 28 degrees C; dew point 23 degrees C; altimeter 29.91 inches of mercury.
TESTS AND RESEARCH
The airplane was recovered from the accident site and examined by a local mechanic. The mechanic reported that each fuel tank contained about 12 gallons of
fuel, and that no fuel or oil leaks were apparent. Oil was present in the sump, and the oil was free of contamination or metal particles. The carburetor bowl was
full of fuel, the spark plugs all exhibited signatures consistent with normal operation, and both magnetos were intact and set to the correct engine timing. The
cylinder compressions were all about 64/80, and the engine controls were intact at their respective linkages, with the carburetor heat control observed in the full
forward (carburetor heat off) position. The examination did not reveal any anomalies with the airframe or engine that would have precluded normal operation.
A mechanic from Trend Vector Aviation subsequently examined the airplane and reported that the left wing fuel tank vent line allowed passage of air, but
appeared to offer greater resistance when compared to other Cessna 172 airplanes in their fleet.
According to representatives from Trend Vector Aviation, the airplane was refueled on the morning of the accident, and subsequently performed an uneventful
flight. Another Cessna 172 was refueled from the same pump, and flew all day without experiencing any problems. After the accident the fuel storage facility
was checked for possible contamination, and none was found.
According to the Cessna 172 service manual, fuel tank venting is accomplished by an overboard vent line incorporated in the left fuel tank. The vent line
protrudes through the bottom of the left wing into the airstream. In addition, a vent crossover line connects the airspace in the left tank to the airspace in the
right tank where a vented fuel tank cap is installed.
The Cessna 172P Pilots Operating Handbook, "EMERGENCY PROCEDURES, Rough Engine Operation or loss of power, Carburetor Icing" section states the
following:
"A gradual loss of engine RPM and eventual engine roughness may result from the formation of carburetor ice. To clear the ice, apply full throttle and pull the
carburetor heat knob full out until the engine runs smoothly; then remove carburetor heat and readjust the throttle. If conditions require the continued use of
carburetor heat in cruise flight, use the minimum amount of heat necessary to prevent ice from forming and lean the mixture for smoothest engine operation."
The carburetor icing probability chart from FAA Special Airworthiness Information Bulletin: CE-09-35 Carburetor Icing Prevention, June 30, 2009, shows a
probability of serious icing at glide power at the temperature and dew point reported at the time of the accident.
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12/01/2012 1900 HST Regis# N3554Y
Acft Mk/Mdl CESSNA 172S
Acft SN 172S8956
Eng Mk/Mdl LYCOMING IO-360-L2A
Opr Name: KRALL JOSE H
Kahului, HI
Apt: Kahului Airport OGG
Fatal
1
Ser Inj
Opr dba:
0
Aircraft Fire: NONE
Events
1. Maneuvering - Loss of control in flight
Narrative
HISTORY OF FLIGHT
On December 1, 2012, at 1900 Hawaiian standard time, a Cessna 172S, N3554Y, impacted the Pacific Ocean about 5 miles from Kahului Airport (OGG),
Kahului, Maui, Hawaii. The owner/pilot operated the airplane under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. The pilot, the
sole occupant, is presumed to have received fatal injuries. The airplane was substantially damaged. Night visual meteorological conditions prevailed for the
flight from OGG to Molokai Airport (MKK), Kaunakakai, Molokai, Hawaii. No flight plan had been filed.
According to the Federal Aviation Administration (FAA), the flight departed about 6 minutes prior to the accident. Shortly before the accident occurred, an Air
Traffic Control (ATC) specialist noted an erratic flight pattern and contacted the pilot. The pilot declined assistance and informed ATC that he planned to make
a right 360-degree turn and track inbound to the MKK VOR. The ATC specialist reported that instead of a right 360-degree turn, the airplane's radar track
showed a left descending turn and was then lost from radar. The FAA reported that the airplane's last known altitude was 700 feet.
The Coast Guard responded to the last known position and commenced search and rescue (SAR) efforts. The Coast Guard recovered a portion of one of the
landing gear, along with some interior airplane pieces; however, the main wreckage was not located. SAR efforts were suspended on December 3, 2012.
The pilot, age 51, held a private pilot certificate with ratings for airplane single engine land. He held a third-class medical issued on January 26, 2012, with no
limitations. No personal flight records were located for the pilot. The National Transportation Safety Board investigator-in-charge (NTSB 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 most recent medical application dated January 26, 2012, that he had a total time of 785 hours with 50 hours logged in
the past 6 months.
The four-seat, high-wing, fixed-gear airplane, N3554Y, Cessna C172S, serial number 172S8956, was manufactured in 2001. It was powered by a Lycoming
IO-360-L2A 160-horsepower. No aircraft logbooks were located for the accident airplane.
METEOROLOGICAL CONDITIONS
Weather conditions reported by OGG, in the accident area were wind from 250 degrees at 7 knots, visibility was 10 statute miles, sky condition was scattered
clouds at 2,500 above ground level (agl), temperature 24 degrees, dew point 19 degrees, and an altimeter setting of 30.03 inches of mercury.
According to a specialists report, calculations made by the RAwindsonde Observation Program (RAOB) did not identify any levels of significant turbulence or
icing, and the freezing level was identified as 14,725 feet. There was a potential for broken to few cloud layers below 3,000 feet.
The Terminal Aerodrome Forecast (TAF) issued at 1325 forecasted for the accident time indicated wind from 360 degrees (true) at 6 knots, visibility greater
than 6 statute miles, few clouds at 5,000 feet agl, and a broken ceiling at 25,000 feet agl. The TAF issued at Kapalua Airport, Lahaina, Hawaii, located about 16
miles west of the airplane's last known position, at an elevation of 256 feet, forecasted for the accident time indicated wind from 290 degrees (true) at 6 knots,
visibility greater than 6 statute miles, few clouds at 4,500 feet agl, scattered clouds at 7,000 feet agl, and a broken ceiling at 25,000 feet agl.
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The Area Forecast (AF) for the Hawaiian Islands issued at 1740 and valid until 0600 on December 2, 2012, reported isolated visibility of 5 statute miles with
haze below 6,000 feet within the area of Oahu to the Big Island. It also advised of scattered or broken ceiling from 20,000 to 25,000 feet msl. The AF directed
toward "Oahu Molokai Lanai and Maui and remainder of Big Island," advised of scattered clouds at 3,000 feet msl, scattered clouds or a broken ceiling at 4,000
feet msl, cloud tops to 7,000 feet msl, and isolated light rain showers with cloud bases at 3,000 feet msl possible.
There were no AIRMETs or SIGMETs issued for the Hawaiian Islands, to include the accident location. There were no pilot reports made below 10,000 feet in
the vicinity of the Hawaiian Islands within 3 hours of the accident time. A detailed report is attached to the docket for this accident.
According to the United States Naval Observatory Astronomical Applications Departments' sun and moon data, sunset was at 1744, and the end of civil twilight
was at 1808.
COMMUNICATIONS
Review of the ATC radar and communication tapes revealed that the pilot was attempting to fly from Maui to Molokai.
According to the tower controller at OGC, the pilot had requested a visual flight rules (VFR) clearance to depart the airport. Prior to taxiing to the active runway,
the pilot requested that the lights be turned up and the controller complied by increasing the intensity of the runway lights to step 3 and verified that that was the
intensity that the pilot wanted. After takeoff, the controller observed a normal climb out. The controller noticed that the accident airplane was about 2 miles
northwest of the field; it made a right turn and began a climb above 1,000 feet. The controller then observed on the radar that the airplane was at 1,500 feet and
had entered into a descent. The controller was able to see the airplane out of his window, but lost sight of the airplane in the darkness. According to the radar,
the airplane was 5 1/2 miles north-northwest of the airport, in a right turn at 500 feet before the radar target entered into a "coast" status. The controller
attempted to find the airplane via binoculars, and then looked back at the radar scope. He observed the pilot's tag pop up about 1/4 mile from the last observed
position proceeding westbound at 700 feet; the radar tag went into a coast status again about 6 miles north of the airport. The controller subsequently received
a call from Honolulu Control Facility (HCF), stating that they had lost radio and radar with the accident pilot and airplane. HCF queried whether or not the pilot
had come over to the tower frequencies. The tower controller broadcasted on the tower, ground, and clearance delivery frequencies, but received no reply from
the pilot.
According to the HCF controller, the accident airplane had been radar identified about 4 miles northwest of OGG, and the pilot was instructed to resume his
own navigation and altitude. The controller noted that the airplane had turned northeast bound and was traveling away from his intended destination. The pilot
was asked to verify his destination, to which he replied requesting radar vectors. The controller asked where the pilot wanted radar vectors to, and if he wanted
an Instrument Flight Rules (IFR) clearance. The pilot declined the IFR clearance and stated that he was destined for Molokai Airport. When the controller asked
if the pilot was tuned into the Molokai VORTAC, the pilot asked for verification that the frequency was 1161.1. The controller stated that the correct frequency
was 116.1. The pilot was requested to report on course to Molokai, and that the radar track was northeast bound and that a 295- or 300-degree heading would
take him to the north side of the airport. The pilot reported that he was going to do a right 360-degree turn, to which the controller asked the pilot to verify his
intentions. The pilot did not respond, and radar contract was lost at 1900. The controller attempted to contact the pilot to no avail.
The controller reported that the pilot sounded clear and calm with no stress apparent during the radio transmissions. The last radar echo showed the accident
airplane in a left turn at 700 feet above the water.
The airplane dropped off radar about 2.5 miles north of Pa'ia, Maui, and about 7 nautical miles northwest of OGG. The airplane was under visual flight rules
(VFR).
The airplane and the pilot were not located. As a result, an autopsy and toxicology could not be performed.
According to the Federal Aviation Administration, during the pilot's last medical exam dated January 26, 2012, the pilot reported high blood pressure and kidney
stones. A review of the pilot's medical history indicated that the high blood pressure was controlled with medication and the history of kidney stones (resolved
issue) should not pose a hazard to flight safety.
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On December 8, 2012, the right wheel and tire washed up on the Kailua Beach Park.
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11/12/2014 1633 EST Regis# N60155
Sarasota, FL
Apt: Sarasota Bradenton Intl SRQ
Acft Mk/Mdl CESSNA 172S
Acft SN 172S10167
Eng Mk/Mdl LYCOMING IO-360-L2A
Acft TT
Fatal
Opr Name: JOSE SANTOS
Opr dba:
3452
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Events
1. Initial climb - Loss of control in flight
Narrative
According to the student pilot, he was performing his second solo flight, and he reported a total flying time of 45 hours. As the airplane became airborne during
the initial takeoff, it ".violently veered 90 degrees to the left." He immediately applied right rudder and reduced the throttle to idle. The airplane was landed on
the left side of the runway and it departed the runway surface, into the grass. It then crossed the intersecting runway. As the airplane approached a taxiway, the
pilot brought it to a full stop. A Federal Aviation Administration inspector reported that the excursion resulted in a buckling of the engine firewall. The student
pilot did not report any mechanical problems with the airplane at the time of the accident. A review of local wind conditions at the airport did not reveal evidence
of gusts.
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03/23/2015 1350 PDT Regis# N2104H
Acft Mk/Mdl CESSNA 172S-S
Acft SN 172S10432
Camarillo, CA
Rpt Status: Prelim
Fatal
0
Opr Name: CHANNEL ISLANDS AVIATION, INC.
Opr dba:
Page 60
Apt: N/a
Ser Inj
Air Data Research
0
Prob Caus: Pending
Aircraft Fire: NONE
All Rights Reserved
08/23/2014 1015 CDT Regis# N3202T
Gordonville, TX
Apt: Cedar Mills Airport 3T0
Acft SN 17700502
Acft TT
Fatal
Opr Name: SINGLETARY KENNETH
Opr dba:
2966
0
Ser Inj
2
Aircraft Fire: NONE
AW Cert: STN
Summary
The pilot reported that he flew a visual approach with a left crosswind to a turf runway. As the airplane descended below a tree line, the wind decreased, and
the airplane drifted left during the landing roll. The pilot applied right rudder, but the airplane did not respond. The airplane departed the left side of the runway
and impacted multiple trees. Examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded
normal operation. After the accident, the pilot stated that he believed the passenger's foot might have blocked the rudder pedals. The accident is consistent
with a loss of directional control during a crosswind landing.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: A loss of directional control
during a crosswind landing.
Events
1. Environmental issues-Conditions/weather/phenomena-Wind-Crosswind-Response/compensation
3. Environmental issues-Physical environment-Object/animal/substance-Tree(s)-Contributed to outcome
Narrative
On August 23, 2014, about 1015 central daylight time, a Cessna 177 airplane, N3202T, impacted trees during landing rollout at Cedar Mills Airport (3T0),
Gordonville, Texas. The pilot and front seat passenger were seriously injured and the two rear seat passengers received minor injuries. The airplane sustained
substantial damage. 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. Day visual meteorological conditions prevailed at the time of the accident and no flight plan was filed. The flight originated from Lakeview Airport
(30F), Lake Dallas, Texas about 0945.
The pilot stated that during a visual approach to Runway 25 at 3T0 he utilized left aileron and right rudder control inputs, based on a crosswind from the south.
As the airplane descended below a tree line, the wind decreased and the airplane drifted to the left. During touchdown and rollout on the turf runway, the
airplane continued to drift to the left. The pilot attempted to input right rudder, but felt like his input was not having any effect. The airplane subsequently
departed the left side of the runway and impacted multiple trees. Examination of the airplane revealed extensive damage to both wings and the fuselage. After
the accident, the pilot stated that the lack of rudder effect may have been due to the front seat passenger's foot blocking a rudder pedal.
At 1015 the weather observation station at North Texas Regional Airport (GYI), Denison, Texas, located about 10 miles southeast of the accident site, reported
the following conditions: wind 200 degrees at 11 knots, visibility 10 miles, clear skies, temperature 31 degrees Celsius (C), dew point 17 degrees C, altimeter
setting 30.02 inches of mercury.
Examination of the airplane revealed normal flight control continuity. The pilot seat was found fully engaged on the rails and locked in position. No secondary
seat stop was observed. The front passenger seat was displaced to the left and separated from the rails. The aft bench was secured to the floor. All seat
restraint belts were still attached to the corresponding structure and no torn stitches were observed. There airplane was not equipped with shoulder harnesses.
Examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation.
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Accident Rpt# ANC15LA011
02/09/2015 1025 AKS Regis# N9280C
Acft SN 31379
Eng Mk/Mdl CONT MOTOR O-470 SERIES
Opr Name: SMITH ALEX
Glennallen, AK
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
0
Prob Caus: Pending
Aircraft Fire: UNK
Events
2. Enroute-cruise - Loss of engine power (partial)
Narrative
On February 9, 2015, about 1025 Alaska standard time, a Cessna 180 airplane, N9280C, sustained substantial damage during a forced landing, following a
possible in-flight fire and partial loss of engine power about 5 miles southeast of Glennallen, Alaska. The certificated airline transport pilot was not injured. The
privately owned airplane was being operated by the pilot as a visual flight rules local personal flight under the provisions of 14 Code of Federal Regulations Part
91 when the accident occurred. Visual meteorological conditions prevailed and no flight plan was filed. The flight originated from the Gulkana Airport, Gulkana,
Alaska about 1000.
In a telephone conversation with the National Transportation Safety Board investigator-in-charge, the pilot stated that the purpose of the flight was to take
photographs in an area east of Glennallen. About 20 minutes into the flight, he noticed the smell of smoke in the cockpit, and immediately began a return to the
airport. Shortly thereafter, the engine began to lose power, and the pilot was unable to maintain altitude. He performed a forced landing in an area of heavily
wooded terrain. After the airplane came to rest, the pilot stated that there was a small fire in the engine cowling that he was able to extinguish by packing snow
into the cowling.
The airplane was equipped with a Spidertracks satellite tracking system, which transmits real-time position reports of the airplane, capable of being viewed from
any computer. After being alerted that the airplane had gone down, a local pilot in the area landed near the accident site, and picked up the pilot.
A detailed examination of the airframe and engine are pending following recovery of the airplane from the accident site.
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03/08/2015 1100 PST Regis# N2030M
Acft SN 18259657
Ramona, CA
Acft Dmg:
Fatal
Opr Name: BERT CRENSHAW
Page 63
Apt: Ramona RNM
0
Rpt Status: Prelim
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire:
All Rights Reserved
12/26/2014 800 CST
Acft Mk/Mdl CESSNA 182P-NO SERIES
Regis# N6063F
Nashville, TN
Acft SN 18264079
Fatal
Eng Mk/Mdl CONTINENTAL MOTORS INC. O-470-U21 Acft TT
Opr Name: AIR LOGISTICS LLC
3448
0
Apt: John C Tune JWN
Ser Inj
Opr dba:
0
Aircraft Fire: NONE
AW Cert: STN
Events
2. Landing-landing roll - Nose over/nose down
Narrative
According to the pilot, he performed a preflight and no anomalies were noted with the airplane. The pilot flew the airplane to another airport, performed a
touch-and-go landing maneuver, and returned to the original departure airport. During the landing roll, the pilot applied the brakes, the airplane veered to the left,
and departed the left side of the runway. The airplane continued through the grass, struck the taxiway pavement, and the nose wheel separated from the
airplane. The airplane traveled across the taxiway and when it impacted the grass on the other side of the taxiway, the airplane nosed over, and came to rest
inverted, which resulted in substantial damage to the rudder. A postaccident examination of the airplane revealed no preimpact mechanical malfunctions or
failures with the airplane that would have precluded normal operation. The pilot reported no preimpact mechanical malfunctions and that "better control of
braking" may have prevented the accident.
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Accident Rpt# CEN15FA174
03/17/2015 1240
Acft Mk/Mdl CESSNA 182Q-Q
Regis# N735KF
El Paso, TX
Acft SN 18265479
Acft Dmg: DESTROYED
Fatal
Eng Mk/Mdl CONT MOTOR O-470-U
Opr Name: BRENTCO AERIAL PATROLS INC
1
Apt: N/a
Ser Inj
Opr dba:
Rpt Status: Prelim
0
Prob Caus: Pending
Aircraft Fire: GRD
AW Cert: STN
Events
1. Maneuvering - Controlled flight into terr/obj (CFIT)
Narrative
On March 17, 2015, about 1240 mountain daylight time, a Cessna 182Q single-engine airplane, N735KF, was destroyed after impacting mountainous terrain
while maneuvering near El Paso, Texas. The commercial pilot, who was the sole occupant, sustained fatal injuries. The airplane was registered to and operated
by Brentco Aerial Patrols, Inc, Canton, Ohio. Instrument meteorological conditions (IMC) prevailed at the time of the accident and a company visual flight rules
(VFR) flight plan was filed for the 14 Code of Federal Regulations Part 91 aerial observation flight. The airplane departed from a private airstrip near Hobbs,
New Mexico, and was destined for the El Paso International Airport (ELP), El Paso, Texas.
According to company representatives, the airplane departed Snyder, Texas, approximately 0855 central daylight time, to perform a pipeline patrol aerial
observation flight with a final destination of ELP. At 1156 central daylight time, the company dispatcher received a telephone call from the pilot who requested
weather information for the southeast New Mexico and El Paso areas. The dispatcher informed the pilot that El Paso was reporting light rain. The pilot told the
dispatcher he was going to depart, and "if he was going to make it, he had better get into the air."
Preliminary radar data showed the accident airplane about 30 miles northeast of ELP and traveling southwest at an altitude of approximately 6,000 feet mean
sea level. Approximately 25 miles northeast of ELP, the airplane was observed to make a left turn towards the south and then execute a right turn back toward
the north. After heading north for approximately 2 miles, the airplane made a left turn toward the west and radar contact was lost.
After company personnel determined the airplane had not arrived at ELP, a search ensued with local authorities. The airplane wreckage was located by local
authorities in mountainous terrain near the last radar contact location approximately 0900 on March 18, 2015.
At 1251, the ELP automated surface observing system, located approximately 22 miles southwest of the accident site, reported the wind from 090 degrees at
12 knots, visibility 7 miles, light rain, few clouds at 2,700 feet, broken clouds at 3,000 feet, sky overcast at 3,800 feet, temperature 16 degrees C, dew point 12
degrees C, and an altimeter setting of 30.13 inches of mercury.
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03/20/2015 1930
Acft Mk/Mdl CESSNA 310Q-Q
Regis# N7770Q
St. George, UT
Acft SN 310Q0270
Rpt Status: Prelim
Fatal
Eng Mk/Mdl CONT MOTOR I0-470 SERIES
Opr Name: REGAN T RICHMOND
0
Apt: St George Muni SGU
Ser Inj
Opr dba:
0
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: STN
Events
1. Landing-landing roll - Landing gear collapse
Narrative
On March 20, 2015, about 1930 mountain daylight time (MDT), a Cessna 310Q, N7770Q, sustained substantial damage follow a main gear collapse during
rollout at St. George Municipal Airport (SGU), St. George, Utah. The owner/pilot was operating the airplane under the provisions of 14 Code of Federal
Regulations (CFR) Part 91. The commercial pilot and one passenger were not injured. The local personal flight departed St George, Utah, about 1845. Visual
meteorological conditions prevailed, and no flight plan had been filed.
The pilot reported that during rollout on runway 19, the left main landing gear collapsed. The airplane veered left and exited the runway. The airplane sustained
substantial damage to the left wing and left horizontal stabilizer.
The airplane was recovered for further examination.
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Accident Rpt# ERA14TA326
07/03/2014 1846 CDT Regis# N3804U
Mobile, AL
Apt: N/a
Acft SN 336-0104
Eng Mk/Mdl CONT MOTOR IO-360 SER
Acft TT
Fatal
Flt Conducted Under: FAR PUBU
Opr Name: MOBILE COUNTY HEALTH
DEPARTMENT
Opr dba:
3151
0
Ser Inj
1
Aircraft Fire: NONE
AW Cert: SPR
Events
1. Maneuvering-low-alt flying - Loss of engine power (partial)
Narrative
On July 3, 2014, about 1846 central daylight time, a Cessna 336, N3804U, force landed following a partial loss of engine power at Mobile, Alabama. The airline
transport pilot was seriously injured, and the airplane was substantially damaged. The airplane was operated by the Mobile County Health Department. Day,
visual meteorological conditions prevailed for the local, public use, aerial application flight, and no flight plan was filed. The local flight originated at St. Elmo,
Alabama (2R5) about 1829.
The pilot reported in a written statement to the NTSB that he was assigned to mosquito control spraying operations in the Mobile area. He departed 2R5 with
about 48 gallons of fuel, including 36 gallons in the auxiliary tanks. While established on the southbound leg of a spray pattern, he transferred the engines, one
at a time, to the full, 18 gallon auxiliary tanks. Shortly after, the engines began to "sputter" and would not maintain rpm. He aborted the spray run, "zoom
climbed" to about 600 feet above the ground (agl), and turned to a heading of about 210, in the direction of Mobile Downtown Airport (BFM), about 4 to 5
nautical miles away. The available power was intermittent with rpm surges on both engines, and power available appeared insufficient to reach BFM. He set up
for a forced landing on an island between a container terminal and a coal terminal. The airplane touched down on soft soil and came to a stop abruptly,
resulting in extensive damage to the airplane.
An inspector with the Federal Aviation Administration responded to the accident site and examined the wreckage. Structural damage to the fuselage was
confirmed. An examination of the fuel system revealed that the fuel selector handle for the front engine was in the right main tank position. The fuel selector
handle for the rear engine was broken off from impact forces. It was later determined that the rear engine fuel selector was also in the right main tank position.
The left and right main fuel tanks were empty of fuel and only residual fuel (about 2 ounces) was drained from the left and right main sump tanks. The tanks
were not breached. The design of main fuel tanks allows them to completely drain into their respective sump tanks. The left and right auxiliary tanks contained
sufficient fuel; however, it was not quantified.
The FAA inspector interviewed the pilot on July 9, 2014. He stated in the interview that he had been flying at 100 feet agl when the rear engine began
"sputtering and coughing." He switched to the auxiliary fuel tank; however, this did not remedy the situation. He climbed the airplane to 500 feet agl and
continued to troubleshoot by switching tanks and turning the boost pumps on. The front engine then began to lose power. He continued to troubleshoot the loss
of power and realized that he could not maintain altitude and needed to perform an emergency landing short of the airport.
The engines were removed from the airframe and sent to the manufacturer's facility for examination. The engines were test run during the week of July 21
through 25, 2014. After repair of impact-related damage, the engines ran normally in a test cell. The test runs did not reveal any abnormalities that would have
prevented normal operation and production of rated horsepower.
On January 16, 2015, the aircraft fuel system was re-examined under the supervision of the NTSB investigator-in-charge. The both engine fuel selectors were
confirmed to be in the right main tank positions. Flaky, rust-colored debris was observed inside the right sump tank. The left sump tank was relatively clean.
The left and right wing auxiliary fuel pumps, which operate the left and right main tank fuel sources only, were found to be functional when energized with a dc
electrical source. The fuel lines from the fuel selector valves to the main and auxiliary tanks were unobstructed.
The rear engine fuel strainer was opened for examination. It contained about 1/8 teaspoon of light gray, powder-like debris in the bowl. The screen was
unobstructed. The supply line from the strainer to the engine-driven fuel pump was obstructed; no air could be blown through it by mouth. The obstruction was
removed with a clean piece of wire; about one teaspoon of light gray, powder-like debris was removed.
The front engine fuel strainer was opened for examination. The bottom of the bowl was corroded with a rust-like substance. The screen was unobstructed. The
supply line from the strainer to the engine-driven fuel pump was obstructed; no air could be blown through it by mouth. The obstruction was removed with a
clean piece of wire; about one half teaspoon of rust-colored, granular debris was removed.
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According to the aircraft manufacturer, the auxiliary fuel tanks are intended for level, cruise flight. The auxiliary fuel tanks gravity feed directly to the fuel
strainer; no boost pumps are available. The Cessna 336 pilot's operating handbook (POH) states that, in the pre-flight exterior inspection and the before landing
checklist, the main tanks are to be selected. Also, the POH states that, in the event of an engine out situation during flight, the main tanks are to be selected if
the auxiliary tanks are in use.
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06/08/2013 1002 EDT Regis# N217JP
Boynton Beach, FL
Acft Mk/Mdl CESSNA 340A
Acft SN 340A0435
Acft Dmg: DESTROYED
Eng Mk/Mdl CONTINENTAL TSIO-520 SER
Acft TT
Fatal
Opr Name: PAUL S. SOULE ENTERPRISES, INC.
Opr dba:
4209
1
Ser Inj
Apt: N/a
0
Aircraft Fire: NONE
Summary
Four minutes after taking off on an instrument flight rules flight, during an assigned climb to 4,000 feet, the pilot advised the departure air traffic controller that
the airplane was having "instrument problems" and that he wanted to "stay VFR" (visual flight rules), which the controller acknowledged. As directed, the pilot
subsequently contacted the next sector departure controller, who instructed him to climb to 8,000 feet. The pilot stated that he would climb the airplane after
clearing a cloud and reiterated that the airplane was having "instrument problems." The controller told the pilot to advise when he could climb the airplane.
About 30 seconds later, the pilot told the controller that he was climbing the airplane to 8,000 feet, and, shortly thereafter, the controller cleared the airplane to
11,000 feet, which the pilot acknowledged. Per instruction, the pilot later contacted a center controller, who advised him of moderate-to-heavy precipitation
along his (northbound) route for the next 10 miles and told him that he could deviate either left or right and, when able, proceed direct to an intersection near his
destination. The pilot acknowledged the direct-to-intersection instruction, and the controller told the pilot to climb the airplane to 13,000 feet, which the pilot
acknowledged. The pilot did not advise the center controller about the instrument problems. The airplane subsequently began turning east, eventually
completing about an 80-degree turn toward heavier precipitation, and the controller told the pilot to climb to 15,000 feet, but the pilot did not respond. After two
more queries, the pilot stated that he was trying to maintain "VFR" and that "I have an instrument failure here." The controller then stated that he was showing
the airplane turning east, which "looks like a very bad idea." He subsequently advised the pilot to turn to the west but received no further transmissions from the
airplane. Radar indicated that, while the airplane was turning east, it climbed to 9,500 feet but that, during the next 24 seconds, it descended to 7,500 feet
and, within the following 5 seconds, it descended to just above ground level (the ground-based radar altitude readout was 0 feet). The pilot recovered the
airplane and climbed it northeast-bound to 1,500 feet during the next 20 seconds. It then likely stalled and descended northwest-bound into shallow waters of a
wildlife refuge. Weather radar returns indicated that the airplane's first descent occurred in an area of moderate-to-heavy rain but that the second descent
occurred in light rain. The ceiling at the nearest recording airport, located about 20 nautical miles from the accident site, was 1,500 feet, indicating that the pilot
likely climbed the airplane back into instrument meteorological conditions (IMC)before finally losing control.The investigation could not determine the extent to
which the pilot had planned the flight. Although a flight plan was on file, the pilot did not receive a formal weather briefing but could have self-briefed via
alternative means. The investigation also could not determine when the pilot first lost situational awareness, although the excessive turn to the east toward
heavier precipitation raises the possibility that the turn likely wasn't intentional and that the pilot had already lost situational awareness. Earlier in the flight,
when the pilot reported an instrument problem, the two departure controllers coordinated between their sectors in accordance with air traffic control procedures,
allowing him to remain low and out of IMC. Although the second controller told the pilot to advise when he was able to climb, the pilot commenced a climb
without further comment. The controller was likely under the impression that the instrument problem had been corrected; therefore, he communicated no
information about a potential instrument problem to the center controller. The center controller then complied with the level of service required by advising the
pilot of the weather conditions ahead and by approving deviations. The extent and nature of the deviation was up to the pilot with controller assistance upon
pilot request. The pilot did not request further weather information or assistance with deviations and only told the center controller that the airplane was having
an instrument problem after the controller pointed out that the airplane was heading into worsening weather. Due to impact forces, only minimal autopsy
results could be determined. Federal Aviation Administration medical records indicated that the 16,560-hour former military pilot did not have any significant
health issues, and the pilot's wife was unaware of any preexisting significant medical conditions.
The wreckage was extremely fractured, which precluded thorough examination. However, evidence indicated that all flight control surfaces were accounted for
at the accident scene and that the engines were under power at the time of impact.
The airplane was equipped with redundant pilot and copilot flight instruments, redundant instrument air sources, onboard weather radar, and a storm scope.
The pilot did not advise any of the air traffic controllers about the extent or type of instrument problem, and the investigation could not determine which
instrument(s) might have failed or how redundant systems could have been failed at the same time. Although the pilot stated on several occasions that the
airplane was having instrument problems, he opted to continue flight into IMC. By doing so, he eventually lost situational awareness and then control of airplane
but regained both when he acquired visual ground contact. Then, for unknown reasons, he climbed the airplane back into IMC where he again lost situational
awareness and airplane control but was then unable to regain them before the airplane impacted the water.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's loss of situational
awareness, which resulted in an inadvertent aerodynamic stall/spin after he climbed the airplane back into instrument meteorological conditions (IMC).
Contributing to the accident was the pilot's improper decision to continue flight into IMC with malfunctioning flight instrument(s).
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Events
1. Enroute-climb to cruise - Flight instrument malf/fail
2. Enroute-climb to cruise - Loss of control in flight
3. Uncontrolled descent - Miscellaneous/other
4. Uncontrolled descent - Collision with terr/obj (non-CFIT)
1. Aircraft-Aircraft systems-Indicating/recording systems-Instrument panel-Failure
2. Personnel issues-Action/decision-Info processing/decision-Decision making/judgment-Pilot - F
3. Environmental issues-Conditions/weather/phenomena-Ceiling/visibility/precip-Below VFR minima-Effect on operation - C
5. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Angle of attack-Not attained/maintained - C
7. Personnel issues-Psychological-Perception/orientation/illusion-Situational awareness-Pilot - C
Narrative
HISTORY OF FLIGHT
On June 8, 2013, at 1002 eastern daylight time, a Cessna 340A, N217JP, was destroyed when it impacted shallow waters of the Loxahatchee National Wildlife
Refuge, near Boynton Beach, Florida. The commercial pilot was fatally injured. Instrument meteorological conditions prevailed in the vicinity, and the airplane
was operating on an instrument flight rules (IFR) flight plan from Fort Lauderdale Executive Airport (FXE), Fort Lauderdale, Florida, to Leesburg International
Airport (LEE), Leesburg, Florida. The business flight was conducted under the provisions of 14 Code of Federal Regulations Part 91.
According to excerpts from the Federal Aviation Administration (FAA) Air Traffic Control Accident Package:
The pilot was cleared to depart FXE utilizing the Fort Lauderdale Three Departure to ARKES intersection, then direct to BAIRN intersection, then as filed [direct
to LEE], climb to 2,000 feet, expect 16,000 feet 10 minutes after departure.
At 0945, the pilot was cleared to take off from FXE runway 8, and to then turn left to heading 310 degrees magnetic. After takeoff, the pilot was cleared to
contact Miami Departure Control.
At 0947, the pilot advised Miami Departure Control that the airplane was passing 600 feet for 2,000 feet, in a left turn, heading 310 degrees. The departure
controller advised radar contact, then cleared the airplane to 4,000 feet, which the pilot acknowledged.
At 0949, the pilot advised that he was having "instrument problems," and that he would like to "head west and stay v-f-r if I can for the climb." The controller
confirmed with the pilot that the airplane was on an IFR flight plan, advised him of traffic ahead, told him to fly heading 270, and directed him switch to the next
departure frequency, which the pilot acknowledged.
At 0950, the pilot contacted the next departure controller, who directed him to climb the airplane to 8,000 feet. The pilot responded that he would do so once he
was clear of a cloud, and reiterated that he had "instrument problems." The controller acknowledged that the pilot would like to keep the airplane at 2,000 feet,
and told the pilot to let him know when he could climb the airplane.
About 30 seconds later, the pilot stated that he was climbing the airplane to 8,000 feet, which the controller acknowledged.
Just before 0954, the controller advised the pilot to turn the airplane right to a heading of 350 degrees, which the pilot acknowledged.
Just before 0956, the controller advised the pilot to climb the airplane to 11,000 feet, which the pilot acknowledged, and at 0958, the controller advised the pilot
to contact Miami Center, which the pilot also acknowledged.
The pilot then contacted Miami Center, and reported passing 6,800 feet for 11,000 feet. The controller provided the local barometric pressure, and advised the
pilot of moderate to heavy precipitation along his route of flight for the next 10 miles. The pilot was given the option of deviating either left or right, and when
able, to proceed direct to BAIRN.
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The pilot responded "BAIRN direct when able."
At 0959:48, the controller instructed the pilot to climb the airplane to 13,000 feet, which the pilot acknowledged.
At 1001:44, the controller advised the pilot to climb and maintain 15,000 feet, but did not receive a response. After two more queries, the pilot stated that he
was trying to maintain v-f-r, "I have an instrument failure here."
The controller then stated, "I'm showing you turning east. That looks like a really bad idea. If you can, turn back to the west to get out of this stuff a lot quicker,
going to the west."
There were no further transmissions from the airplane.
Radar data indicated that at 1000:26, the airplane began a turn from a northerly heading approaching 90 degrees, toward the east, completing it about 1001:01.
At 1001:11, the airplane reached its maximum altitude of 9,500 feet, still heading eastbound. By 1001:25, the airplane had descended to 8,100 feet, and by
1001:30, it had descended to 7,900 feet. At 1001:35, the altitude indicated 7,500 feet, and at 1001:40, the altitude indicated 0 feet (ground based altitude
readouts are indicated in nearest 100-foot increments).
There was no radar indication at 1001:45, but a renewed eastbound track began with a 0-foot altitude at 1001:50, 300 feet at 1001:55, 600 feet at 1002:00,
1,100 feet at 1002:05 and 1,500 feet at 1002:10. The airplane then turned to the northeast, with the last radar contact at 1,400 feet, at 1002:15.
PILOT INFORMATION
The pilot, age 75, held a commercial pilot certificate with airplane single engine land, multi-engine land and instrument airplane ratings. He also held a flight
instructor certificate and was previously a U.S. Air Force pilot.
According to the pilot's logbook, as of June 1, 2013, he had 16,560 total hours of flight time, including 11,166 hours in multi-engine airplanes, 2,702 hours of
actual instrument flight time and 736 hours of simulated instrument flight time. In the previous 30 days, the pilot logged 4.3 hours of actual instrument flight time
and 11.3 hours of simulated instrument flight time.
The pilot's latest FAA Second Class Medical Certificate was issued on August, 21, 2012, and a review of FAA pilot medical records did not reveal any
significant issues.
The pilot's wife indicated that the pilot was on a business trip, but did not know his activities the day and night before the accident or who he may have met
with. The pilot's wife also stated that that she was unaware of any significant preexisting medical conditions, and that there was no pressing need for the pilot to
return home that day.
According to the aircraft logbook, the latest annual inspection was completed on September 1, 2012, at an airframe time of 4,209.4 hours. At that time, both
engine logbooks indicated that 100-hour inspections were completed, with both engines having 1,392.7 hours of operation since major overhaul.
The aircraft logbook also noted that, as of December 12, 2012, with no airframe hours stated, the flight director was overhauled. Other electronics items were
removed for "configuration, interface and alignment with flight director. Autopilot was ground checked and a successful flight check was performed."
On January 25, 2013, at 4,230.2 hours, the left auxiliary fuel pump was removed and replaced with an overhauled pump.
The last logbook entry, on March 18, 2013, at 4,238.6 hours, "complied with visual inspection AD2001-01-16 no defects noted." According to FAA website
information, that airworthiness directive applied to exhaust systems on certain Cessna 300 and 400 airplanes.
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Photographs of the cockpit, taken in 2009 by a previous pilot when the airplane's registration was N226LD, showed six primary flight instruments forward of the
pilot's yoke; an attitude indicator (gyro) over a horizontal situation indicator (gyro) in the center, an airspeed indicator over a turn and slip indicator to the left of
those, and an altimeter over a vertical speed indicator to the right. To the right of the altimeter was the autopilot mode selector. To the right of that was a
Garmin GNS 530 nav/comm and below that, a Garmin GNS 430 nav/comm. To the right of the GNS 530 was a weather radar, and to the left of the GNS 430,
an Insight Strikefinder.
In front of the copilot's yoke, there was another airspeed indicator. To the right of that was another attitude gyro, and the right of that, another altimeter.
According to FAA-H-8083-25, "Pilot's Handbook of Aeronautical Knowledge," an airspeed indicator measures the difference between pitot, or impact air
pressure, and static pressure. The altimeter and vertical speed indicator (rate-of-climb indicator) operate with static air only.
According to the airplane model's Pilot's Operating Handbook (POH),
The airplane had two independent pitot pressure systems, one for the pilot-side airspeed indicator, and one for the copilot-side airspeed indicator. Each system
had its own pitot tube located on either side of the airplane nose cap. Heat to each pitot tube could applied via a cockpit switch.
Static pressure for the pilot-side airspeed, altimeter and rate-of-climb indicators was obtained via a normal static source aft of the main cabin door. In the event
of normal static air blockage, an alternate source from within the airplane's nose compartment could have been selected by the pilot.
Copilot instruments received static pressure from a completely independent source.
The POH also noted that the proper operation of the airspeed, altimeter and rate-of-climb indicators could be determined by cross-checking the copilot
instruments. In addition, "when a climb or descent is initiated, these instruments should indicate an appropriate change. If on change is indicated, it would be
reasonable to assume that a static source blockage has occurred and that the alternate static source should be selected. If only the airspeed indicator appears
to be affected when a climb or descent is initiated, it would be reasonable to assume that a pitot system blockage has occurred."
A vacuum system was installed to provide a source of vacuum for the vacuum instruments. The system included an engine-driven pump on each engine, a
pressure relief valve for each pump, a common vacuum manifold with check valves, a vacuum air filter, and one vacuum suction gauge with failure indicator for
left and right. Each vacuum pump would create a vacuum on the common manifold, exhausting the air overboard.
The POH further stated that vacuum air powered the pilot-side horizontal and directional gyros, and the copilot-side horizontal and directional gyros. If one
vacuum pump failed, the manifold check valves would isolate the failed pump and the suction indication for the respective pump would move to the failed
position. No corrective action was required by the pilot, as the system would automatically isolate the failed vacuum source, allowing normal operation via the
remaining operative vacuum pump.
Surface weather, recorded at West Palm Beach International Airport, West Palm Beach, Florida, located about 060 degrees magnetic, 20 nm from the accident
site, at 0953, included wind from 120 degrees true at 7 knots, visibility 2 statute miles, thunderstorm, heavy rain, ceiling 1,500 feet broken, 2,800 feet overcast,
temperature 23 degrees C, dew point 23 degrees C, altimeter setting 30.07 inches Hg.
Ground based weather radar indicated that the airplane transitioned from an area of "green" intensity (30-35 dBZ reflectivity- light precipitation) to "yellow"
(35-40 dBZ reflectivity - moderate precipitation), then "orange" (40-45 dBZ reflectivity- heavier precipitation) as it was first losing altitude. It then climbed back
up into an area of "green" intensity precipitation.
Ground based weather radar also indicated that the airplane's turn to the right was toward heavier precipitation, while a straight course at that time would have
initially kept the airplane in lighter precipitation.
There were no convective or non-convective Significant Meteorological Information (SIGMET) advisories active for the accident location at the accident time.
There were also no Airmen's Meteorological Information (AIRMET) advisories active for the accident location at the accident time.
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The wreckage was located in swampy terrain with water depths varying to about 5 feet. The initial impact point located in the vicinity of 26 degrees 30.48
minutes north latitude, 080 degrees, 24.59 minutes west longitude, or about 1,500 feet north of the last radar position. The wreckage was highly fragmented,
and was dispersed along an approximately 320-degree magnetic heading. The first recognizable item at the initial impact point was the left tip tank.
The two engines were recovered, but without a propeller attached to either one. A propeller was eventually located, but was initially unrecoverable. Both engine
propeller flanges were fractured, with some material missing as were some flange bolts, and other bolts were sheared off. Neither engine exhibited any
evidence of pre-impact failure, nor did either vacuum pump. The cockpit vacuum pressure gauge was found frozen at 5.8 psi.
Subsequent to the departure of the investigative team, additional material, including the one propeller, was recovered. Examination of the additional wreckage
occurred on November 5, 2013, with representatives from the airplane and engine manufacturers, with FAA oversight. At the time, all flight control surfaces
were accounted for, but flight control continuity could only be partially confirmed due to the amount of fragmentation of the wreckage.
Pitot tubes were not observed, but a pitot tube cover was seen in a box that had been in the airplane.
An autopsy was performed on the pilot at the District 15, State of Florida, Office of the District Medical Examiner, West Palm Beach, Florida. The cause of
death was determined to be "multiple blunt traumatic injuries." Non-recovery of internal organs precluded complete examination.
Toxicological testing was performed at the FAA Forensic Toxicology Research Team, Oklahoma City, Oklahoma. No blood was available for testing. Ethanol
was present in muscle and brain tissue with putrefaction (post-mortem decomposition) noted on the report.
Flight Planning
According to Lockheed Martin Flight Services (LMFS) Quality Assurance (QA), no [weather briefing] services were provided for N217JP. LMFS QA also noted
that DTC (Data Transformation Corporation) DUATS (Direct User Access Terminal Service) also did not provide any services, but that CSC (Computer
Sciences Corporation) did have a flight plan on file.
Air Traffic Control Services
During a recorded conversation following the accident between the "Miami Center Operations Manager in Charge" (OMIC), and an air traffic quality control
group (QCG) official, the following was stated:
OMIC: "By the time he's telling him, think it's a bad idea to go to the right, the guy had already been committed going to the right to begin with and got in trouble.
QCG: "All right, so we may have led him down the garden path."
OMIC: "Yeah, by giving him that option and mentioning you can go right or left."
FAA Order JO 7110.65 "Air Traffic Control" states, in part:
"2-6-4. WEATHER.SERVICES
a. Issue pertinent information on observed/reported weather and chaff areas by defining the area of coverage in terms of azimuth (by referring to the 12-hour
clock) and distance from the aircraft or by indicating the general width of the area and the area of coverage in terms of fixes or distance and direction from
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fixes.
Weather significant to the safety of aircraft includes such conditions as funnel cloud activity, lines of thunderstorms, embedded thunderstorms, large hail, wind
shear, microbursts, moderate to extreme turbulence (including CAT), and light to severe icing.
c. Use the term 'precipitation' when describing radar-derived weather. Issue the precipitation intensity from the lowest descriptor (LIGHT) to the highest
descriptor (EXTREME) when that information is available. Do not use the word 'turbulence' in describing radar-derived weather.
g. When requested by the pilot, provide radar navigational guidance and/or approve deviations around weather or chaff areas. In areas of significant weather,
plan ahead and be prepared to suggest, upon pilot request, the use of alternative routes/altitudes."
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Incident Rpt# ERA12IA559
09/10/2012 1650 EDT Regis# N218LG
Opa-locka, FL
Apt: Opa-locka Executive Airport OPF
Acft Mk/Mdl CESSNA 402B
Acft SN 402B0218
Acft Dmg: MINOR
Eng Mk/Mdl CONT MOTOR TSIO-520 SER
Acft TT
Fatal
Opr Name: WAYMAN AVIATION SERVICES INC
Opr dba:
8216
0
Ser Inj
0
Aircraft Fire: NONE
Events
2. Taxi-from runway - Landing gear collapse
Narrative
On September 10, 2012, about 1650 eastern daylight time, a Cessna 402B, N218LG, landed at Opa-Locka Executive Airport (OPF), Miami, Florida, and after
clearing the runway, the right main landing gear collapsed. The airline transport-rated pilot and two passengers were not injured. The airplane sustained minor
damage. The airplane was registered to and operated by Waymen Aviation Services Inc. 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 OPF at 1600.
The pilot stated that, while turning left off of the active runway after landing, the airplane "began veering to the left," and the right main landing gear
subsequently collapsed. The right main landing gear was examined by a Federal Aviation Administration inspector, and he confirmed the damage to the right
main landing gear assembly.
The landing gear bellcrank was sent to the NTSB materials laboratory for examination. The bellcrank consisted of a long arm, approximately 7.5 inches long,
and a short arm, approximately 2.1 inches long, with a 105-degree included angle between the two. The end of each arm was shaped in the form of a clevis.
One of the clevis knuckles on the long bellcrank arm was fractured. The fracture surface had a rough appearance and was at an angle to the longitudinal axis of
the clevis arm, consistent with an overstress fracture. No other anomalies were noted with the landing gear.
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04/01/2013 1635 EDT Regis# VQTIN
Fort Lauderdale, FL
Apt: Fort Lauderdale Executive FXE
Acft Mk/Mdl CESSNA 402C
Acft SN 402C0227
Eng Mk/Mdl CONTINENTAL TSIO-520-VB1F
Acft TT
Fatal
Flt Conducted Under: FAR NUSN
Opr Name: CAICOS EXPRESS AIRWAYS
Opr dba:
8524
0
Ser Inj
0
Aircraft Fire: NONE
Summary
Before the accident flight, maintenance had been conducted on the foreign-registered airplane at a Federal Aviation Administration-authorized repair station.
After takeoff, the pilot selected the landing gear to the "up" position. The pilot noticed that the main landing gear retracted but that the nose landing gear did not.
He then "completed the emergency check," selected the gear "down" position, and subsequently observed three "gear down and locked" lights illuminate. After
discussing the situation with an air traffic controller, the pilot decided to return to the airport to land. The touchdown was normal; however, during the landing
roll, as the airplane decelerated, the nose landing gear collapsed, and the airplane's nose and propellers contacted the runway, which resulted in substantial
damage to the airplane.
Examination of the nose landing gear assembly revealed that the nose landing gear actuator was intact, extended, and undamaged but that the rod end, which
had its castellated nut still threaded onto it, was not connected to the nose landing gear drag brace. Review of maintenance records and discrepancy sheets
revealed no evidence that maintenance had been performed on the nose landing gear assembly. However, review of worksheets that the operator had given to
the repair station indicated that the operator had requested that nondestructive testing (NDT) be performed on the nose landing gear drag brace. Although the
worksheets were supposed to be used to document the inspections, repair station personnel did not fill them out. However, a work order sent to the operator by
the NDT technician, who was a contractor, did indicate that NDT had been performed on the nose landing gear drag brace. The repair station's chief inspector
stated that, for previous NDT of the nose landing gear brace, repair station personnel had always removed the part from the airplane. However, after the chief
inspector met with the operator's mechanic and the pilot to discuss the maintenance to be performed, they decided that the repair station did not have to be
involved in the NDT that day because the nose landing gear brace actually did not need to be removed for the NDT. Thus, the chief inspector did not enter the
NDT on the discrepancy sheets.
The chief inspector reported that, initially, no one involved in the airplane's maintenance could remember if anyone had worked on or near the nose landing
gear; however, a mechanic subsequently reported that he had disconnected and removed the bolt from the nose landing gear actuator at the request of the
NDT technician to facilitate the NDT of the nose landing gear. The chief inspector further reported that neither the mechanic nor the NDT technician
communicated to anyone that the bolt had been removed or took any actions that might have alerted anyone that the bolt was not in place; evidence indicates
that the bolt was not reinstalled, which could have been detected during a postmaintenance inspection. However, the chief inspector reported that, because the
nose landing gear drag brace inspection was not on the discrepancy sheet and it had not been removed for maintenance, it did not occur to him to inspect it
before releasing the airplane to service. The inspector's failure to inspect the drag brace led to its being returned to service without the bolt attached and its
subsequent failure. The evidence indicates that confusion existed regarding what each person's and organization's responsibilities were and that a breakdown
in communication occurred between the repair station personnel, the NDT technician, and the operator. These factors, coupled with the lack of oversight by the
chief inspector, led to a breakdown in the controls put in place to detect and correct errors before an accident occurs. Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The disconnection of the nose
landing gear actuator, which resulted in the subsequent collapse of the nose landing gear. Contributing to the accident was the repair station's inadequate
maintenance, postmaintenance inspection process, and oversight of the maintenance performed and the lack of communication between the repair station
personnel, the operator, and the testing technician.
Events
1. Prior to flight - Aircraft maintenance event
2. Prior to flight - Aircraft inspection event
3. Takeoff - Miscellaneous/other
4. Initial climb - Landing gear not configured
5. Maneuvering - Attempted remediation/recovery
6. Landing - Off-field or emergency landing
7. Landing - Landing gear not configured
8. Landing - Landing gear collapse
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1. Aircraft-Aircraft systems-Landing gear system-Nose/tail landing gear-Incorrect service/maintenance - F
2. Aircraft-Aircraft systems-Landing gear system-Nose/tail landing gear-Not inspected - F
3. Personnel issues-Action/decision-Action-Forgotten action/omission-Maintenance personnel - F
4. Personnel issues-Task performance-Maintenance-Installation-Maintenance personnel - F
5. Personnel issues-Task performance-Inspection-Post maintenance inspection-Maintenance personnel - F
6. Organizational issues-Support/oversight/monitoring-Documentation/record keeping-Maintenance records-Maintenance provider - F
7. Organizational issues-Support/oversight/monitoring-Oversight-Oversight of maintenance-Maintenance provider - F
8. Aircraft-Aircraft systems-Landing gear system-Nose/tail landing gear-Failure - C
9. Personnel issues-Task performance-Communication (personnel)-Lack of communication-Maintenance personnel - F
10. Organizational issues-Management-Communication (organizational)-Between groups/organizations-Maintenance provider - F
11. Organizational issues-Management-Communication (organizational)-Between groups/organizations-Operator - F
12. Organizational issues-Management-Communication (organizational)-Within group(s)/organization-Maintenance provider - F
Narrative
HISTORY OF FLIGHT
On April 1, 2013, at 1635 eastern daylight time, a Cessna 402C, Turks and Caicos Islands registration VQ-TIN, operated by Caicos Express Airways (CEA),
was substantially damaged when the nose landing gear collapsed during landing rollout at Fort Lauderdale Executive Airport (FXE), Fort Lauderdale, Florida.
The airline transport pilot was not injured. Visual meteorological conditions prevailed and an IFR flight plan was filed for the positioning flight, destined for
Providenciales International Airport (MBPV), Providenciales, Turks and Caicos Islands. The flight was conducted under the provisions of Article 14 of the
United Kingdom Air Navigation (Overseas Territories) Order 2007.
According to the pilot, the airplane had just had maintenance completed and the purpose of the flight was to return the airplane to MBPV to place it back in
service. After departing from runway 26 at FXE, the pilot selected the landing gear to the "UP" position. The pilot noticed however, that the main landing gear
retracted but, the nose landing gear did not. He then "completed the emergency check" and immediately selected "gear down". He then observed three "gear
down and locked lights". After discussing the situation with air traffic control the pilot decided to return for landing on runway 13. The touchdown was normal,
however during the rollout, as the airplane decelerated through 60 knots, the nose landing gear collapsed and the airplane's nose and propellers made contact
with the pavement. The pilot also advised that prior to the nose landing gear collapse, he never heard a gear warning horn.
According to Federal Aviation Administration (FAA) and pilot records, the pilot held an airline transport pilot certificate with a rating for airplane multi-engine
land. His most recent FAA first-class medical certificate was issued on October 23, 2012. He reported that he had accrued 10,566 total hours of flight
experience, 3,507 of which were in the accident airplane make and model.
According to Turks and Caicos Islands Civil Aviation Authority (TCI-CAA) and CEA records, the airplane was manufactured in 1980. Its most recent annual
inspection was completed on March 16, 2013. At the time of the inspection, the airplane had accrued 8,524 total hours of operation.
The recorded weather at FXE at 1653, included: wind 180 degrees at 5 knots, visibility 10 miles, sky clear, temperature 26 degrees C, dew point 17 degrees C,
and an altimeter setting of 29.97 inches of mercury.
Examination of the airplane revealed that the fuselage nose structure behind the radome had been substantially damaged.
Examination of the nose landing gear assembly revealed that the nose landing gear actuator was intact, extended, and undamaged, but the rod end with its
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castellated nut still threaded onto it was not connected to the nose landing gear drag brace. Further examination of the nose landing gear assembly also
revealed that it would have been difficult for the pilot to discover that the nose landing gear actuator was disconnected from the nose landing gear drag brace,
as the disconnected actuator was in an area that would be difficult for him to see or access.
TESTS AND RESEARCH
Review of Maintenance Records
According to FAA and TCI-CAA records, the repair station which performed the maintenance on the airplane; EA Management Services Inc. (EAMS), was
authorized to perform both airframe and powerplant repair on CEA aircraft.
Review of the airplane's maintenance records revealed however, no evidence of any maintenance being performed on the nose landing gear assembly. Review
of the EAMS defect work cards for the maintenance performed on the airplane also did not reveal any evidence of maintenance being performed on the nose
landing gear assembly.
Review of the additional worksheets (Form CEA-124) which had been given to EAMS to be used to document additional inspections as part of the maintenance
requested by CEA, indicated that the nose landing gear drag brace (Supplemental Inspection Number: 32-20-00) was requested to be performed. The
documents however were discovered to have not been filled out by EAMS.
Review of a work order (Work Order: 2013-0051) that was sent to CEA by Ultimate NDT Inc. indicated however that non-destructive testing (NDT) had been
performed on the nose landing gear drag brace in the form of a fluorescent penetrant inspection and that no cracks were noted at the time of the inspection.
CHIEF INSPECTOR'S STATEMENTS
According to EAMS's chief inspector, on March 24, 2013, the accident airplane was flown into FXE by the pilot and one of CEA's mechanics to have
maintenance performed, which included an engine change and numerous Supplemental Inspections in accordance with Chapter 4 of the airplane maintenance
manual. One of the mechanics that normally worked for the repair station was also contracted by CEA to assist in performing the maintenance for the duration.
According to the chief inspector, upon the airplane's arrival, they immediately began to prepare the airplane for the inspection and engine change as they had
tentatively scheduled March 27, 2013 as the date that non-destructive testing (NDT) inspections were to be performed by a contractor. Using the work order
instructions as a guide, the chief inspector prepared a list of the NDT inspections to be carried out by the NDT contractor. This list was compiled based on the
chief inspector's knowledge of the airplane and his familiarity with its maintenance history.
The chief inspector's list included some additional inspections that were not originally included on the work order instruction supplied by CEA. This list was
presented and after discussions with the mechanic from CEA and the pilot, it was decided that the repair station did not need to be involved in the inspection of
the nose landing gear drag brace, because it did not necessitate the dismantling or separation of any parts. According to the chief inspector, this discussion
happened on March 24, 2013 but, he was unable to recall the specific details, though according to him, "it was unequivocal that we had agreed that our help will
not be needed in the performance of this inspection at this time." On previous inspections of the nose landing gear drag brace, the repair facility had always
completely removed the drag brace from the airplane and the inspection was carried out with the part removed from the airplane. The chief inspector also
advised that they discussed the unavailability of paint stripper and the need to purchase some to carry out the inspection. After he was informed that this was
not required he did not transfer that inspection to the out shop defect work cards (discrepancy sheets).
According to the chief inspector, they proceeded to complete the inspections, installations and other additional maintenance as required by CEA and on their
work order. He advised that he was responsible for the supervision of all tasks and upon their completion; he did a final inspection, ground runs for the engine
installation, and the control adjustments and release to service.
After the accident, when the examination found that the bolt that connected the nose gear drag link to the nose gear actuator was disconnected, initial
questioning of all parties that were involved in the maintenance of the aircraft, as to whether anyone may have worked on and therefore disconnected the nose
actuator bolt, was conducted. Everyone involved answered in the negative. No one at the time could remember anyone working on the nose landing gear or
working in the vicinity of the nose landing gear.
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Further questioning revealed that a mechanic had indeed disconnected and removed the bolt at the request of the NDT technician to facilitate an inspection on
the nose landing gear. The mechanic and NDT technician at no time communicated this to anyone and did not take any further actions that may have alerted
anyone to the bolt not being in place.
According to the chief inspector, they had performed this inspection numerous times at their facility and the contracted NDT technician had always had the
nose landing gear drag brace removed, the inspection areas paint stripped, and then placed on a table, to conduct the inspection. According to the chief
inspector they were unaware that this inspection could have been carried out in-situ on the aircraft. He advised that, since it was not on their discrepancy
sheet, and since they did not remove it for maintenance, and being unaware that this inspection could have been carried out without the drag brace being
removed from the aircraft, at no time did it occur to him to inspect the drag brace before the release to service.
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03/23/2014 1410 EDT Regis# N211PP
St. Petersburg, FL
Apt: Albert Whitted SPG
Acft Mk/Mdl CESSNA O1 - A
Acft SN 22956
Eng Mk/Mdl CONTINENTAL IO-470
Acft TT
Fatal
Opr Name: ST. PETE AERIAL ADVERTISING
Opr dba:
10140
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Events
1. Initial climb - Loss of engine power (total)
Narrative
On March 23, 2014, about 1400 eastern daylight time, a Cessna O-1A, N211PP, operated by Advertising Airforce, was substantially damaged when it collided
with water during a forced landing following a total loss of engine power during climb-out from Albert Whitted Airport (SPG), St. Petersburg, Florida. The
commercial pilot was not injured. Visual meteorological conditions (VMC) prevailed, and no flight plan was filed for the banner-tow flight, which was conducted
under the provisions of Title 14 Code of Federal Regulations Part 91.
According to the operator, the pilot had completed a two-hour flight and subsequently serviced the airplane with 16.5 gallons fuel. He then completed a second
banner tow flight, which was one hour in duration, before picking up a third banner. The pilot's first pick-up attempt was unsuccessful. He circled the pick-up
location for a brief period, and completed the pick-up on the second attempt. During the initial climb, about 300 feet, the engine experienced a total loss of
power. The pilot released the banner and completed a forced landing to Tampa Bay. The pilot reported that the entire flight was conducted on the left main fuel
tank.
The pilot held a commercial pilot certificate with ratings for airplane multiengine land, single engine land and instrument airplane. He also held a flight instructor
certificate with a rating for airplane single engine. His most recent Federal Aviation Administration (FAA) second class medical certificate was issued on May
31, 2013. He reported 3,070 total hours of flight experience, of which 2,863 hours were in single-engine airplanes.
At the time of the accident, the weather reported at SPG included winds from 260 at 12 knots. The temperature was 25 degrees C, and the dew point was 19
degrees C.
According to FAA and maintenance records, the airplane was manufactured in 1951. Its most recent 100-hour inspection was completed February 27, 2013, at
10,140 aircraft hours. The airplane was powered by a 213 horsepower, Continental O-470-11, six-cylinder, horizontally opposed, air-cooled engine with a
pressure carburetor. The airplane was equipped with four fuel tanks; with one main tank and one auxiliary tank in each wing. Each main tank had a capacity of
20.5 gallons, of which 18 gallons were usable. Each auxiliary tank had a capacity of 12 gallons, of which 11.5 gallons were usable.
The airplane was recovered from the water and examined by an FAA inspector. Examination and then draining of the fuel tanks revealed that the right main and
auxiliary tanks were full and contained "some" sea water. The left auxiliary tank was full and contained some sea water, and the 18-gallon left main tank was
empty, dry, and contained no traces of fuel or water. The fuel selector was found in the right main tank position, and the fuel boost pump was in the off position.
When interviewed, the pilot stated he did not remember switching the fuel selector to the right tank, and thought the selector remained in the left tank position.
The engine was flushed with water and diesel fuel to preserve it, and slave magnetos were mounted. The airplane was serviced with fuel, a new battery was
installed, and an engine start was attempted. The engine started immediately, and ran continuously without interruption.
Interpolation of a fuel consumption chart located in the manufacturer's operating handbook indicated that, in cruise flight, on a standard day (15 degrees C, sea
level), the airplane would consume approximately 7 gallons per hour at 2,000 rpm, and 10 gallons per hour at 2,300 rpm. These numbers assume a clean
configuration (wing flaps retracted), with no banner in tow.
According to a representative of the engine manufacturer, the airplane's engine was a military variant of the O-470, which could consume as many as 21
gallons per hour in a full-power climb.
According to the operator's copy of the Pilot Operating Handbook (POH) in use at the time of the accident, item 6 of the DESCENT checklist:
"Fuel selector valve handle - Fullest tank."
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The operator's training syllabus stated, "While flying, periodically check your fuel supply, oil pressure and temperature, magnetos, and carburetor heat."
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03/28/2015 1800 CDT Regis# N2093J
Acft Mk/Mdl CESSNA T188C-C
Opr Name: RUCKER DARLENE M
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Acft SN T18803383T
Burdett, KS
Apt: Rucker Burdett SN29
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire: NONE
All Rights Reserved
04/11/2014 1800 EDT Regis# N156SA
Louisa, VA
Apt: Louisa County LKU
Acft Mk/Mdl CESSNA U206G
Acft SN U20605670
Eng Mk/Mdl CONTINENTAL IO-520 SERIES
Acft TT
Fatal
Opr Name: LASER MAPPING SPECIALISTS INC
Opr dba:
3370
0
Ser Inj
1
Aircraft Fire: NONE
Events
Narrative
On April 11, 2014, about 1800 eastern daylight time (EDT), a Cessna U206G, N156SA, force landed following a total loss of engine power near Louisa, Virginia.
The commercial pilot received serious injuries, one passenger received minor injuries, and the airplane was substantially damaged. The airplane was operated
by Laser Mapping Specialists, Inc. under the provisions of 14 Code of Federal Regulations Part 91. Day, visual meteorological conditions prevailed for the
aerial laser mapping flight, and no flight plan was filed. The flight originated at Louisa County Airport (LKU) about 1730.
The pilot reported the following. During a flight prior to the accident, the engine oil pressure slowly fluctuated up and down, but within the normal range. He
elected to change the engine oil and noted "a great deal of chrome" inside the oil filter. He placed a magnet inside the metallic particles and found no ferrous
material. Four cylinders were replaced in December, 2013, so he attributed the particles in the oil to "break-in." After consulting the pilot's operating handbook,
he believed that the oil pressure fluctuations were due to a gauge problem or a clogged pressure relief valve. He elected to continue with his planned flight.
After routine ground operations, the flight departed. About 30-40 minutes into the flight, the engine started making "a strange sound" and then "quit" about 20
seconds later. He force landed the airplane in an open field. The airplane landed hard and came to rest, resulting in structural damage to the airframe.
According to personnel at LKU, prior to the accident flight, the pilot requested supplies for an oil and filter change following a reported anomaly with the
airplane's oil pressure gauge. The pilot performed the engine oil and filter change himself. The pilot opened the oil filter and "an excessive amount of metal" was
observed inside the filter. The local airport personnel expressed their concerns about the metallic debris, and the pilot stated that he would contact his personal
mechanic and obtain his opinion and advice. The pilot completed the oil change and prepared to depart the airport. After topping off the fuel tanks, the pilot and
passenger departed on runway 27.
A review of the engine maintenance records revealed that, on December 20, 2013, the numbers 2, 3, 4, and 5 cylinders were removed and replaced with
overhauled cylinders provided by the customer. The cylinders were replaced due to low compression.
Following the accident, the engine was removed and shipped to the manufacturer's facility for examination. Prior to disassembly, it was noted that, after rotation
of the propeller flange, internal continuity was not established to the rear accessory pad. The crankshaft would only rotate through 90 degrees of travel.
Disassembly of the engine revealed that the breakaway torque values of the through bolts at the cylinder flanges were at various values; however, only the
torque bolts associated with the number 6 cylinder were at or above the manufacturer's recommended torque value. The torque values in the loosen direction
for the numbers 1-5 top through bolts ranged from 534 to 705 inch-pounds (790 to 810 inch-pounds recommended). The torque values in the loosen direction
for the numbers 1-5 bottom through bolts ranged from 458 to 675 inch-pounds (790 to 810 inch-pounds recommended).
The engine oil pan and oil cooler were removed from the engine. The oil pan revealed metal particulates of various sizes and the oil cooler revealed metal
particulates inside the unit. The engine exhibited substantial internal damage in the area of the number 2 main bearing. The crankshaft was observed fractured
in the immediate vicinity of the number 2 main bearing. According to Continental Motors personnel, a crankshaft failure associated with a bearing shift will
usually fail in fatigue and this crankshaft failure exhibited failure signatures consistent with fatigue. The adjacent areas around the number 2 main bearing
exhibited scoring on the inside of the engine case, and the numbers 1 and 3 main bearings also exhibited evidence of bearing movement prior to the engine
failure.
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03/02/2015 1252 EST Regis# N787Z
Boynton Beach, FL
Acft Mk/Mdl COLYAER SL FREEDOM-S100
Acft SN 130-001-027
Acft Dmg: DESTROYED
Eng Mk/Mdl ROTAX 912ULS
Acft TT
Fatal
Opr Name: WHITNEY DAVID
Opr dba:
146
2
Ser Inj
Apt: N/a
Rpt Status: Prelim
0
Prob Caus: Pending
Aircraft Fire: GRD
AW Cert: SPE
Events
1. Enroute-cruise - Miscellaneous/other
Narrative
On March 2, 2015, about 1252 eastern standard time, a Colyaer Freedom S100, N787Z, was destroyed after it impacted terrain and a postcrash fire ensued
near Boynton Beach, Florida. The airline transport pilot and student pilot were fatally injured. Visual meteorological conditions prevailed and no flight plan was
filed for the local personal flight conducted under the provisions of Title 14 Code of Federal Regulations Part 91, that departed from Palm Beach County Park
Airport (LNA), West Palm Beach, Florida at 1218.
Preliminary radar data indicated that the airplane had been operating over a wildlife refuge area for approximately 25 minutes prior to the accident. According to
witnesses who were fishing about a half mile from the accident site, they also observed the airplane flying over the wildlife refuge, and then heard the airplane
engine make a sound that resembled a cylinder misfire, similar to what they had heard their boat motor do. The engine then "revved up" almost
instantaneously, which was followed by a loud boom about thirty seconds later. The witnesses then rushed to the accident site, and observed smoke coming
from the wreckage. About a minute later a postcrash fire ensued.
Examination of the accident site revealed that the airplane had come to rest upright in a swamp on a southeasterly heading about 40 feet from a berm. All
major components of the airplane were accounted for. The wings had remained attached to the fuselage and exhibited some fire damage. Both wing flaps and a
portion of the left wing aileron were destroyed by fire. A portion of the right wing tip, that measured about 70 inches in length, was impact separated. The
fuselage, with the exception of the cockpit hull, and the empennage, were completely destroyed by fire. The elevator had separated from the tail section and
was located several feet behind the main wreckage. All three composite propeller blades were fracture separated from the propeller hub. A section of propeller
blade that measured about 15 inches in length was co-located with the main wreckage. The other two propeller blades were not recovered. Examination of the
accident site and wreckage revealed that the airplane was not rotating around the vertical axis at impact.
Postaccident examination of the airframe was conducted After recovery from the accident site. Continuity of the elevator flex control cable was confirmed from
the elevator to the elevator flight controls. Both left and right aileron flex cables were attached to the aileron and displayed continuity to the center bell crank.
The wing flap control system was not recovered. The airplane was equipped with three fuel tanks; a left wing tank, a right wing tank, and a fuselage tank. Both
wing tanks were destroyed by fire. The fuselage tank remained intact; however, the fuel lines were burned and the fuel vent was impact damaged. The
gascolator filter was free of debris and the gascolator bowl was void of contamination. The right and left occupants' rudder pedals moved synchronously, which
actuated the center bell crank assembly and push rods. There was approximately six inches of push rod, which extended from the rudder into the vertical
stabilizer. The rudder control tubes that connected to the push rod at the vertical stabilizer were not recovered. The throttle and choke controls were confirmed
from the throttle/choke quadrant to the carburetors.
The pilot held a FAA airline transport pilot license with a rating for airplane multi-engine land. His most recent FAA first-class medical certificate was issued on
February 4, 2015. At that time, he reported 19,400 hours of total flight experience of; of which, about 149 hours were in the airplane make and model.
A handheld Garmin 496 global positioning system receiver was recovered from the cockpit and forwarded to the NTSB Vehicle Recorder Laboratory,
Washington, DC, for download.
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Accident Rpt# ERA15LA124B
02/09/2015 615 EST
Acft Mk/Mdl DEHAVILLAND DHC 6 200
Opr Name: EAGLE AIR TRANSPORT INC
Regis# N70EA
Sebastian, FL
Acft SN 139
Rpt Status: Prelim
Fatal
0
Apt: Sebastian Municipal X26
Ser Inj
Opr dba:
0
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: STN
Events
1. Standing-engine(s) not oper - Ground collision
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Accident Rpt# ERA15LA124A
02/09/2015 615 EST
Acft Mk/Mdl DEHAVILLAND DHC 6 TWIN OTTER
Opr Name: EAGLE AIR TRANSPORT INC
Regis# N30EA
Sebastian, FL
Acft SN 191
Rpt Status: Prelim
Fatal
0
Apt: Sebastian Municipal X26
Ser Inj
Opr dba:
0
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: STN
Events
1. Standing-engine(s) start-up - Loss of control on ground
Narrative
On February 9, 2015 at 0615 eastern standard time, N30EA, a DH6 Twin Otter sustained substantial damage when it collided with N70EA, another DH6 Twin
Otter, during engine start at the Sebastian Municipal Airport (X26), Sebastian, Florida. Neither the pilot on N30EA or N70EA were injured. Both airplanes were
registered to and operated by Eagle Air Transport, Ottawa, Illinois. An instrument flight rules flight plan was filed for the re-positioning flight that was destined for
the Exuma International Airport (MYEF), George Town, Bahamas. Visual meteorological conditions prevailed for the positioning flight conducted under the
provisions of 14 Code of Federal Regulations Part 91.
Both airplanes were parked right next to each other, wing-tip to wing-tip. N30AE was parked on the right side of N70AE. The pilot of N30AE stated that she had
just started the engines. When she advanced the throttles (one at a time) to bring the generators on-line, the airplane began to move forward. She said she tried
to apply the brakes, but they were not working and she was unable to move the tiller, which was positioned all the way to the left. The pilot was unable to stop
the airplane and it collided with N70AE.
The pilot of N70AE said that had not started the engines yet when N30AE struck his airplane.
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01/29/2014 1515 CST Regis# N24RB
Memphis, TN
Apt: General Dewitt Spain M01
Acft Mk/Mdl ENSTROM F 28A-A
Acft SN 057
Eng Mk/Mdl LYCOMING HIO 360 C1A
Acft TT
Fatal
Opr Name: HELICOPTERS INC
Opr dba:
10760
0
Ser Inj
0
Aircraft Fire: NONE
Events
2. Landing-flare/touchdown - Sys/Comp malf/fail (non-power)
Narrative
HISTORY OF FLIGHT
On January 29, 2014, about 1515 central standard time, an Enstrom F-28A helicopter, N24RB was substantially damaged during landing at General Dewitt
Spain Airport (M01), Memphis, Tennessee. The flight instructor and private pilot were not injured. The airplane sustained substantial damage to a main rotor
blade and the tail rotor driveshaft. The helicopter was registered to and operated by a flight school under the provisions of 14 Code of Federal Regulations Part
91 as an instructional flight. Visual meteorological conditions prevailed and no flight plan was filed for the local flight that departed M01 about 1340.
According to the flight instructor's written statement, they had practiced several running landings with simulated stuck anti-torque pedal approaches; each
approach varied between the right pedal, left pedal, and neutral position. While the student completed some of the landings, the flight instructor guarded the
cyclic and collective flight controls and, at times, took control of the helicopter and demonstrated the maneuver to completion. The flight instructor reported that
during a low power steep approach the profile and alignment with the landing zone on final approach appeared "correct" and the speed before touchdown was
approximately 10 mph. During touchdown, the landing skids collapsed and the helicopter came to rest in a nose-down attitude.
Post-accident examination of the helicopter by a Federal Aviation Administration (FAA) inspector revealed substantial damage to the tail boom and the tail rotor
drive shaft. According to photographs taken by the FAA inspector, the tail boom was damaged in multiple sections with evidence of bending. The tailrotor drive
shaft was found 100 feet away from the helicopter; one end displayed torsional damage and the other end displayed evidence consistent with shearing. Two of
the three main rotor blades were undamaged and the inboard trailing section of the third main rotor blade was split open. The third main rotor blade also
exhibited compression wrinkles throughout the length of the blade. Examination of the landing skid revealed a broken skid tube clamp which was recovered to
the NTSB materials laboratory for further inspection. The FAA inspector reported no mechanical malfunctions or anomalies with the control system that would
The pilot held a flight instructor certificate with ratings for airplane single-engine land, instrument airplane, and helicopter. He also possessed a commercial
certificate with ratings for single-engine land, multi-engine land, helicopter, instrument airplane, and instrument helicopter. The pilot reported 5,260 total hours of
flight experience, of which about 2,000 hours were in the accident helicopter make and model.
The student held a private pilot certificate with ratings for helicopter and instrument helicopter. He reported 225 total hours of flight experience, of which 142
hours were in the accident helicopter make and model.
The helicopter was a single-engine, three-place helicopter with skid type landing gear. It was manufactured in 1971 and had accrued 10,000 total aircraft hours.
It was powered by a four cylinder, 205 horsepower, Lycoming HIO-360-CIA engine. Its most recent 100 hour inspection was completed on November 22, 2013,
at 9,930 total aircraft hours.
According to the maintenance records, the landing gear was inspected on November 22, 2013 in accordance with the 100 hour inspection checklist which
stated, "Check landing gear for cracks in weld areas, bolts at all attach and pivot points for excessive wear." The maintenance manual does not require the
removal and examination or replacement of any of the skid tube clamps during the lifetime of the helicopter.
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Based on the maintainer's recounted history of the helicopter's time in service, the helicopter had three prior hard landing events that resulted in repairs, but the
maintenance records did not contain any entries related to the examination, repair or replacement of the skid tube clamp in the helicopter's 44 year history.
According to a representative of the airframe manufacturer, the broken skid tube clamp recovered from the wreckage was identified as part #34 in Enstrom IPC
7-51. This particular clamp connected the landing gear leg to the cross tube. He added that the landing gear leg, oleo strut, and the outboard portion of the
cross tube form a triangle. During landing, forces push up on the skid at the bottom corner of the "triangle" where the oleo strut and the leg attach. The "triangle"
will pivot around the upper end of the oleo strut where it attaches to the end of the cross tube, which places the skid tube clamp in tension where the top of the
leg attaches.
The representative of the airframe manufacturer reported multiple landing gear failures in a span of 20 years. During this time the clamps were either broke or
cracked, but the damage was always attributed to overstress due to hard landings, and never examined or evidence of fatigue.
The 1454 recorded weather at MEM, located about 9 nautical miles south of the accident site, included calm wind, clear skies, 10 miles visibility, few clouds
25,000 feet, temperature 1 degree C, dewpoint minus 17 degrees C, and an altimeter setting of 30.37 inches of mercury.
Materials Laboratory
The skid tube clamp was composed of two halves, which were affixed on one side by a bolt. The upper clamp half was bent and twisted outward and the
attached ring exhibited features on its fracture surface that were consistent with overstress. The fracture surface of the upper clamp half, opposite a weld,
contained numerous ratchet marks, consistent with progressive cracking from multiple initiation sites. The lower clamp half was fractured near the welded ring;
the clamp half exhibited no indications of plastic deformation. The mating fracture surface, adjacent the weld, displayed fatigue striations indicative of fatigue
crack propagation. Multiple cracks had initiated at the weld where the ring joined the lower clamp and propagated inward through the thickness of the clamp.
Chemical examination of the lower clamp revealed a composition that was consistent with alloy steel. The composition of the ring was also consistent with an
alloy steel; however, different from the clamp and with a notably lower chromium content. The weld material was consistent with commonly used weld filler
steels. Hardness testing revealed that the weld material was soft compared to the clamp and ring, which progressively increased in hardness closer to the weld.
The hardness was highest between the heat-affected zone near the weld and the weld, which corresponds with the fatigue crack initiation areas of the clamp
and ring.
The weld cracks were not visible, and could only be detected by magnetic particle or dye penetrant inspection.
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03/07/2015 1400 CDT Regis# N87EV
Acft Mk/Mdl ERCOUPE 415 C-C
Acft SN 958
Eng Mk/Mdl CONT MOTOR A&C75 SERIES
Opr Name:
St Jacob, IL
Apt: St Louis Metro-east 3K6
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
0
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: STN
Events
1. Approach-VFR go-around - Loss of engine power (total)
Narrative
On March 7, 2015, about 1400 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, St Jacob, Illinois. The private pilot was uninjured. The airplane sustained
substantial firewall and wing damage. The airplane was registered to and operated by an individual under the provisions of 14 Code of Federal Regulations Part
91 as a personal flight. Day visual flight rules conditions prevailed for the flight, which did not operate on a flight flight plan. The flight originated from the A Paul
Vance Fredericktown Regional Airport, near Fredericktown, Missouri, about 1130.
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.
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01/04/2014 1530 EST Regis# N611SP
Canton, GA
Apt: Cherokee County CNI
Acft Mk/Mdl FK LIGHTPLANES FK9 ELA SW
Acft SN 09-419
Eng Mk/Mdl ROTAX 912ULS
Acft TT
Fatal
Opr Name: JOHN HANSEN
Opr dba:
591
0
Ser Inj
0
Aircraft Fire: NONE
Events
3. Landing-landing roll - Landing gear collapse
Narrative
HISTORY OF FLIGHT
On January 4, 2014, about 1530 eastern standard time, a FK Lightplanes FK9, light-sport airplane, N611SP, was substantially damaged following a partial loss
of engine power while in cruise flight near Canton, Georgia. The pilot subsequently made an off airport forced landing to an open field. The certificated private
pilot and passenger were not injured. Visual meteorological conditions prevailed and no flight plan was filed for the flight destined for Cobb County Airport McCollum Field (RYY), Kennesaw, Georgia. The fight originated from Mustang Field Airport (0GA1), Hartwell, Georgia, about 1500. The airplane was registered
to and operated by a private individual under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight.
According to the pilot, while in cruise flight the fuel pressure gauge indicated a decrease in fuel pressure from 5.4 gallons per hour (gph) to 0.1 gph and the rpm
subsequently decreased. After activating the auxiliary fuel pump, he was able to restart the engine; however, only partial power was restored. Unable to
maintain altitude, an off airport emergency landing was performed to a nearby field. Upon landing the airplane encountered a berm, became airborne, and
landed hard, which resulted in the left main landing gear and nose landing gear to separating from the airplane.
The pilot, age 30, held a private and sport pilot certificate for airplane single-engine land, and a third-class medical certificated issued December 10, 2012. The
pilot reported 83.7 total flight hours with 16.8 of those hours in the accident aircraft make and model.
The two-seat, high-wing, fixed-gear airplane was built in 2010. It was powered by a Rotax 912ULS 100-hp engine and was driven by a Warpdrive DUC 3-blade
fixed-pitch propeller. The most recent condition inspection was completed on March 5, 2013 with a recorded aircraft time in service of 503.0 hours. According to
the pilot, at the time of the accident, the aircraft had accumulated 590.9 total hours.
The recorded weather at Cherokee County Airport (CNI), Canton, Georgia, which was located 8 miles to the northwest of the accident location, included
overcast clouds at 1500 feet above ground level, wind from 090 degrees at 9 knots, temperature 2 degrees C, and dew point -11 degrees C.
Examination of the airplane by a Federal Aviation Administration (FAA) inspector revealed that it came to rest with the left wing contacting the ground and the
firewall was damaged. The left wing fuel tank had an undetermined amount of fuel and the right wing fuel tank was devoid of fuel. Initial examination of the
engine revealed compression on all cylinders and the automotive fuel, that was located throughout the fuel system, was free of debris.
Examination of the engine by a representative from the engine manufacturer, with FAA oversight, revealed that the engine remained attached to the airframe
and that the spark plugs appeared "normal" in appearance. The electric fuel pump was tested and was operational, fuel was present in the fuel bowls, and the
airframe fuel vent tube was observed with no blockage noted. The engine was started and operated at normal power settings utilizing the fuel from the aircraft,
with no abnormalities noted. Further examination revealed that the float chamber vent lines had been routed from the carburetor into the air filter. The engine
did not have, nor was it required to have, carburetor heat and utilized radiant heating from the engine to minimize carburetor icing possibilities.
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Rotax Installation Manual
A review of the Rotax installation manual for the 912 Series engine, Chapter 15.1 "Requirements on the carburetor" provided a caution message which stated in
part, "The float chamber venting lines have to be routed into a ram-air and vacuum free zone or into the airbox.these lines must not be routed into the
slipstream or down the firewall. Pressure differences between intake pressure in the carburetor chambers may lead to engine malfunction due to incorrect fuel
supply."
According to a representative from the engine manufacturer, the routing of the carburetor venting line to the air filters influenced the fuel-air mixture of the
engine and, in certain flight conditions, the engine may experience a lack of fuel due in part to the back pressure in the float bowl exceeding the normal
operating range.
FAA Special Airworthiness Information Bulletin
A review of FAA Special Airworthiness Information Bulletin, CE-09-35, dated June 30, 2009, revealed that the temperature and dew point at CNI was not
conducive to carburetor icing.
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03/18/2015 1145 EDT Regis# N566FD
Acft Mk/Mdl FLIGHT DESIGN GMBH
Opr Name:
Page 92
Acft SN 08-03-06
Mount Vernon, OH
Apt: Knox County 4I3
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire: NONE
All Rights Reserved
11/17/2013 555 EST
Regis# N132FW
Kenansville, NC
Acft Mk/Mdl FOCKE-WULF FWP 149D-D
Acft SN 132
Acft Dmg: DESTROYED
Eng Mk/Mdl LYCOMING-BMW GO-480-B1A6
Acft TT
Fatal
Opr Name: PARKER LUKE G
Opr dba:
4763
1
Ser Inj
Apt: Duplin County Airport DPL
0
Aircraft Fire: NONE
Events
1. Approach - Controlled flight into terr/obj (CFIT)
Narrative
HISTORY OF FLIGHT
On November 17, 2013, about 0555 eastern standard time, a Focke-Wulf FWP 149D, N132FW, was destroyed while on approach to Duplin County Airport
(DPL), Kenansville, North Carolina. The commercial pilot was fatally injured. The airplane was registered to and operated by the pilot under the provisions of 14
Code of Federal Regulations (CFR) Part 91 as a personal flight. Instrument meteorological conditions prevailed, and no flight plan was filed. The airplane
departed the Albert J. Ellis Airport (OAJ), Jacksonville, North Carolina at 0543, which is 20.9 nautical miles southeast of DPL.
According to the wife of the pilot, he was planning a flight to Michigan to attend a funeral of a friend. On the night before the accident, the pilot told his wife that
he had planned to leave in the morning, depending on the weather, but he did not give a definite time. He went on to say that he would stop in Henderson Field
Airport, Wallace, North Carolina (ACZ), for fuel and then stop at a midway point to refuel again before continuing to Michigan. He said that there was a cold
front moving in, and he was keeping an eye on it and needed to be prepared. The pilot's wife asked him to call her when he left and landed. On November 18,
2013, after attempts to contact the pilot were unsuccessful, the local authorities and the Federal Aviation Administration were notified by the pilot's wife that his
airplane had not arrived at his destination airport. An immediate search began, and an Alert Notice (ALNOT) was issued. The airplane was located by ground
crews on the evening of November 18, at 2213.
According to a lineman at OAJ, on the morning of the accident, he noticed an airplane taxing on the ramp. He was able to see the aircraft beacon and a
silhouette of the airplane but was unable to see the registration number of the aircraft. Shortly thereafter, he heard the airplane takeoff and head towards the
west. He recalled that the weather at the time was very foggy.
PILOT INFORMATION
The pilot, age 37, held a commercial pilot certificate for airplane single-engine land with instrument airplane issued January 7, 2011, and a second-class airman
medical certificate issued February 13, 2009, with no limitations. Review of the pilot's logbook revealed that he accumulated 656 flight hours as pilot in
command and a total of 695 in make and model. Further review revealed that 23 flight hours were completed within the last 30 days before the accident. It was
also noted that the pilot had a total of 62.8 hours of actual instrument time and a total of 50.8 hours of simulated instrument (HOOD) time.
The three-seat, low-wing, retractable-gear airplane, serial number 132, was manufactured in 1960. It was powered by a Lycoming Flugmotor GO-480-BIA6,
serial number L4506, 264-horsepower engine equipped with MT propeller D94315. Review of copies of maintenance logbook records showed a conditional
inspection was completed February 19, 2013, at a recorded airframe total time of 4,308.3 hours and a total time of 5,160.6 hours. Examination of the airplane
revealed that the airplane was equipped with the required instruments and equipment required for instrument flight in accordance with CFR part 91, Subpart C,
91.205.
According to a lineman at OAJ, he assisted the pilot in servicing the nose strut two days prior to the accident. He stated that no other maintenance was
performed on the airplane.
AERODROME INFORMATION
Duplin County Airport is a non-towered airport with a field elevation of 134.5 feet. The airport was equipped with a single asphalt runway 5/23 (6,002 feet long
and 75 feet wide). The runway was equipped with runway end identifier lights and precision approach path lights (PAPI). According to the airport manager the
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PAPI lights were out of service and all other lighting systems were operational. The runway was not equipped with runway edge lights or touchdown point lights
and there is a published localizer instrument procedure for the airport.
There was no record that the pilot obtained an official preflight weather briefing.
The recorded weather at the OAJ at an elevation of 93 feet, revealed at 0555, conditions were winds calm, cloud conditions overcast at 200 feet above ground
level (agl). Visibility 1/2 mile, temperature 54 degrees Celsius (C); dew point 52 degrees C; altimeter 30.16 inches of mercury. A review of the recorded weather
observations for OAJ revealed that all reports between 0335 and 0955 reported overcast ceilings at 200 feet agl.
The recorded weather at DPL at an elevation of 137 feet, revealed at 0555, conditions were winds calm, cloud conditions overcast at 100 feet agl, visibility 1/2
mile and fog, temperature 54 degrees Celsius (C); dew point 54 degrees C; altimeter 30.17 inches of mercury.
COMMUNICATIONS
Radar data was reviewed from the New River Marine Corps Air Station (NCA), Jacksonville, North Carolina. It revealed that, on November 17, 2013, between
the hours of 0525 local until 0555 local, a primary target was observed 1 mile north of OAJ tracking northwest toward DPL. The primary target appeared on the
scope at 0543:52. No secondary target was observed. Radar was lost at 0546:27, and then reappeared at 0546:45. The target was again lost 8 miles northwest
of OAJ, or 20 miles northwest of NCA, at 0547:57, and the target did not reappear. The airplane was not transmitting a mode C signal during the flight.
The wreckage was located in a wooded area 1/2 mile from the approach end of runway 23 at DPL. All flight surfaces and major components were located at the
accident site. The airplane was resting nose-down at the base of a tree. The wreckage debris path was about 100 yards long and on a magnetic heading of 230
degrees. The propeller and engine were buried about 4 feet in a crater.
Examination of the cockpit revealed that it was crushed aft, and the instrument panel was crushed. The flight controls were still in their respective positions.
The cockpit canopy was separated from the fuselage and located along the debris path. The flight instruments were impact-damaged. Both navigational
indicators were captured at a heading of 230 degrees.
Examination of the cockpit revealed control stick continuity from the stick to the bell crank and out to the flight control surfaces. The fuel selector valve was
observed in the right tank position. The rudder pedals were connected to the rudder bar, and the rudder control cables were traced to the bell crank in the
empennage out to the rudder. The left and right aileron trim tabs were impact-damaged, and the position was unreliable. The nose gear was observed broken
off of the strut.
Examination of the empennage revealed that the vertical and horizontal stabilizers were still attached and impact-damaged. The left and right horizontal
stabilizers were buckled aft and revealed accordion crushing on the leading edge. The elevators were connected to the horizontal stabilizers and
impact-damaged.
Examination of the left wing revealed that it was separated from the fuselage at the wing root. The left wing was fragmented with accordion crushing on parts of
leading edge. The left aileron was separated from the wing and located along the debris path and impact-damaged. Flight control cables were observed
attached to the fragmented sections of the wing and exhibited overload fractures. The left flap assembly was separated from the wing and located along the
debris path and impact- damaged. The left main landing gear was separated from the wing and located along the debris path. The left main fuel tank was
breached and located in the wreckage debris path. The fuel cap was observed on a fragment of the wing and was locked with a tight seal.
Examination of the right wing revealed that the wing was still attached to the fuselage. According crushing was observed along the leading edge and impact
damage throughout the span of the wing. The wing tip was separated from the wing and located along the debris path. The aileron was attached to the wing and
impact damaged. The flap assembly was attached to the wing and impact damaged. The position of the flap could not determine. The right main landing gear
was in the down and locked position. The landing gear position switch was observed in the down position. The right main fuel tank cap was locked with a tight
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seal. Examination of the fuel tank revealed that approximately 5 gallons of fuel was observed in the tank and it was breached.
The propeller remained attached to the gearbox driveshaft flange. The propeller spinner was partially crushed. The blade marked "A" exhibited twisting and
curling of the outboard portion of the blade. The blade marked "B" was bent forward about mid-span and aft near the tip. That blade exhibited twisting and
leading and trailing edge "S" bends. The blade marked "C" was curved aft about 90 degrees at about mid-span.
Examination of the engine revealed that is was rotated by turning the propeller. Continuity of the crankshaft to the rear gears and to the valve train was
confirmed. Compression and suction was observed from all six cylinders. All spark plugs were removed and exhibited dark gray color. The Nos.1 and 3 top and
bottom spark plugs were oily. Oil drained from the No. 1 cylinder when the lower spark plug was removed and it was noted that when the airplane came to rest
it was in a nose down position at the accident site. The interiors of the engine cylinders were examined using a lighted borescope and no anomalies noted. The
pressure carburetor was fractured across the throttle bore and separated from the engine. The throttle and mixture controls were impact damaged and their
positions were unreliable. The carburetor fuel inlet screen was unobstructed. The pressure regulator section was disassembled and no damage noted tor the
rubber diaphragms. The engine driven fuel pump remained attached to the engine and no damage was noted. Liquid with an odor and color consistent with that
of aviation gasoline ran from the pump inlet hose when the pump was removed. The fuel pump produced fuel from the outlet hose when the inlet hose was
submerged in fuel and the pump drive rotated using a battery operated drill. At the conclusion of the engine examination no anomalies were noted that would
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05/02/2013 1629 EDT Regis# N8AS
Catskill, NY
Apt: Hudson River NONE
Acft Mk/Mdl GRUMMAN G-44
Acft SN 1315
Acft Dmg: DESTROYED
Eng Mk/Mdl LYCOMING GO-480-B1D
Acft TT
Fatal
Opr Name: BRAUNSTEIN MICHAEL B
Opr dba:
2251
1
Ser Inj
0
Aircraft Fire: GRD
AW Cert: STN
Events
1. Landing - Aerodynamic stall/spin
Narrative
HISTORY OF FLIGHT
On May 2, 2013, about 1629 eastern daylight time a Grumman, G44 seaplane, N8AS, was substantially damaged when it impacted the waters of the Hudson
River during a water landing, near Catskill, New York. The certificated airline transport pilot was fatally injured. Visual meteorological conditions prevailed, and
no flight plan had been filed for the local personal flight conducted under Title14 Code of Federal Regulations Part 91, which departed from B Flat Farm Airport
(3NK8), Copake, New York about 1600.
Approximately 25 witness interviews were conducted. Descriptions varied between witness statements as to the altitude, direction of flight, and velocity of the
airplane; however, the preponderance of witness statements were that the airplane was first observed flying southbound low above the Hudson River and the
airplane's engines could heard to be running. The airplane then made a 180 degree left turn until it had reversed direction and was flying in a northerly direction.
The airplane descended, leveled off above the surface of the water, then suddenly banked to the left and struck the water with the nose and left pontoon, nosed
over, then caught fire, and sank.
According to Federal Aviation Administration (FAA) and pilot records, the pilot held an airline transport pilot certificate with multiple ratings including airplane
multi-engine land and airplane multi-engine sea, commercial privileges for airplane single engine land and airplane single engine sea, and a type rating for the
G-73.
His most recent FAA third-class medical certificate was issued on February 2, 2012, with limitations that required him to wear lenses that correct for distant
vision and possess glasses that correct for near vision. He also possessed a statement of demonstrated ability for defective color vision.
He had accrued approximately 5,735 total hours of flight experience of which approximately 411 hours, were in the accident airplane make and model.
The accident aircraft was a twin engine, high wing, tail wheel equipped, amphibious airplane of conventional metal construction. It was powered by two 295
horsepower, horizontally opposed, air cooled, geared, 6-cylinder engines, driving three bladed, constant speed, variable pitch propellers.
According to FAA and maintenance records, the airplane was manufactured in 1943. The airplane's most recent annual inspection was completed on May 25,
2012. At the time of the accident, the airplane had accrued 2,251 total hours of operation.
The recorded weather at Albany International Airport (ALB), Albany, New York, located approximately 29 nautical miles north of the accident site, at 1651,
included: winds 190 degrees at 3 knots, visibility 10 miles, few clouds at 9,000 feet, temperature 27 degrees C, dew point 03 degrees C, and an altimeter
setting of 30.29 inches of mercury.
Review of the National Oceanic and Atmospheric Administration Tide Prediction Chart for the area of the accident indicated that at the time of the accident the
river was at slack tide.
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Witnesses described the water conditions at the time as calm.
Accident Site Examination
The airplane came to rest on the bottom of the Hudson River in 20 to 25 feet of water. Examination of the river bottom utilizing side scan sonar revealed that
the airplane had broken apart and that the major portions of the airplane were contained within an approximately 250 foot long debris field oriented on a 039
degree magnetic heading.
Wreckage Examination
Examination of the wreckage recovered from the debris field revealed that the airplane break up occurred during the impact sequence and not prior to impact
with the water. Further examination revealed that the damage pattern was consistent with witness observations, with the airplane having made contact with the
surface of the river with the airplane's nose first, then the left float, in a left wing low, nose down attitude.
Evidence of a postcrash fire was evident primarily in the area of the right main fuel tank where it had been breached by the right engine nacelle structure during
the impact sequence. There was no evidence of an inflight fire.
Continuity was established from the ailerons, rudder, and elevator to the breaks in the flight control system which displayed evidence of tensile overload and
from the breaks in the flight control system, to the control column and rudder pedals.
The landing gear handle was in the up position and examination of the main landing gear wheels up catches, and tail wheel retracting bell crank assembly,
indicated that the landing gear was in the up position during the impact sequence.
Examination of the wing flaps revealed that they were in the extended position during the impact sequence.
All fuel caps were closed. The fuel valve levers for the left and right tank were in the "ON" position and the "TANK CROSS-FLOW" lever was in the "OFF"
position.
The left engine and right engine alternator field switches were "ON," and the battery switch was "ON". The left engine, and right engine, magneto switches were
each in the "BOTH" position.
Examination of the Left Engine
After recovery from the debris field, examination of the left engine revealed, that the propeller, propeller governor, gearbox assembly, and carburetor, had been
separated from the engine during the impact sequence. They were not recovered.
The drive train could not be rotated by hand. However, after the rear mounted accessories, and the No. 2, No. 4, and No. 6 cylinders were removed, continuity
of the crankshaft to the rear gears and to the valve train was able to be confirmed visually, and water, rust, and silt, were observed in the removed cylinder
barrels.
Oil was observed to be present inside the engine, and the engine driven fuel pump could be rotated by hand.
Both magnetos produced intermittent sparks when rotated by hand and internal examination revealed the presence of water and corrosion.
The spark plugs appeared normal with undamaged electrodes, with the exception of the No.2 cylinder's bottom sparkplug which had been destroyed during the
impact sequence. Water and silt were present in the electrode wells of the surviving top and bottom sparkplugs.
The starter, generator, and vacuum pump, remained attached to the engine, and all appeared to be undamaged.
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Examination of the Right Engine
After recovery from the debris field, examination of the right engine revealed, that the propeller and gearbox assembly, along with the carburetor, and portions
of the induction and exhaust systems had been separated from the engine during the impact sequence.
The propeller governor had remained attached to the gearbox assembly. One propeller blade was twisted in the propeller hub, and bent aft about 90 degrees at
approximately the mid-span position. The second propeller blade was twisted in the propeller hub, was curved slightly forward, and exhibited twisting towards
the face of the blade. The third propeller blade was bent aft 45 degrees about 12 inches outboard of the hub, and exhibited heavier twisting towards the face of
the blade, and curling of the propeller tip.
The drive train could not be rotated by hand. However, after the rear mounted accessories, and the No. 1, No. 3, and No. 5 cylinders were removed, continuity
of the crankshaft to the rear gears and to the valve train was able to be confirmed visually, and water, rust, and silt, were observed in the removed cylinder
barrels.
Oil was observed to be present inside the engine, and the engine driven fuel pump could be rotated by hand.
The left magneto would produce spark when rotated by hand. Internal examination revealed the presence of water and corrosion.
The right magneto would not produce spark when rotated however, internal examination of the magneto revealed the water in the magneto point's compartment.
The spark plugs appeared normal with undamaged electrodes, with the exception of the No. 1 cylinder's top and bottom sparkplugs, and the No. 2 Cylinder's
bottom sparkplug which displayed impact damage. Water and silt were present in the electrode wells of the surviving top and bottom sparkplugs.
The starter, generator, and vacuum pump, remained attached to the engine, and the vacuum pump produced water when rotated by hand, all appeared to be
undamaged.
An Autopsy was performed on the pilot by St. Peter's Hospital Laboratory Department of Pathology on behalf of the Greene County Coroner.
Cause of death was massive blunt force injuries.
Toxicological testing of the pilot was conducted at the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The specimens from
the pilot were negative for carbon monoxide, cyanide, basic, acidic, and neutral drugs with the exception of:
- Diclofenac; which is a nonsteroidal anti-inflammatory drug with analgesic and antipyretic activity.
- Rosuvastatin; which is a member of the drug class of statins, used to treat high cholesterol and related conditions, and to prevent cardiovascular disease.
- Valsartan; which is an angiotensin receptor blocker indicated for treatment of high blood pressure.
Both Diclofenac and Valsartan had been previously reported to his Aviation Medical Examiner.
TESTS AND RESEARCH
Glassy Water
According to the FAA's Seaplane, Skiplane, and Float Equipped Helicopter Operations Handbook (FAA-H-8083-23), Glassy water conditions are defined as a
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calm water surface with no distinguishable surface features, with a glassy or mirror like appearance which can deceive a pilot's depth perception.
When landing, the flat, featureless surface makes it far more difficult to gauge altitude accurately, and reflections can create confusing optical illusions. The
Handbook advises that when the wind is calm or light, or when the water is like a mirror, or when ripples with the appearance of scales are formed without foam
crests, that pilots should check their glassy water technique before water flying under these conditions.
The handbook advised, that flat, calm, glassy water looks inviting and may give a pilot a false sense of safety. By its nature, glassy water indicates no wind, so
there are no concerns about which direction to land, no crosswind to consider, no weathervaning, and obviously no rough water. Unfortunately, both the visual
and the physical characteristics of glassy water hold potential hazards. Consequently, this surface condition is frequently more dangerous than it appears for a
landing seaplane as the visual aspects of glassy water make it difficult to judge the seaplane's height above the water.
The handbook also advised that the lack of surface features can make accurate depth perception very difficult, even for experienced seaplane pilots. Without
adequate knowledge of the seaplane's height above the surface, the pilot may flare too high or too low, and that either case could lead to an upset.
If the seaplane flares too high and stalls, it will pitch down, very likely hitting the water with the bows of the floats and flipping over. If the pilot flares too late or
not at all, the seaplane may fly into the water at relatively high speed, landing on the float bows, driving them underwater and flipping the seaplane.
Glassy Water Landing Technique
According to FAA-H-8083-23, there are some simple ways to overcome the visual illusions and increase safety during glassy water landings. Perhaps the
simplest is to land near the shoreline, using the features along the shore to gauge altitude. The handbook advises though to assure that the water is sufficiently
deep and free of obstructions by performing a careful inspection from a safe altitude.
Another technique is to make the final approach over land, crossing the shoreline at the lowest possible safe altitude so that a reliable height reference is
maintained to within a few feet of the water surface.
When adequate visual references are not available, the handbook advised to make glassy water landings by establishing a stable descent in the landing
attitude at a rate that will provide a positive, but not excessive, contact with the water.
The handbook also advised to recognize the need for this type of landing in ample time to set up the proper final approach, to always perform glassy water
landings with power, and to perform a normal approach, but prepare as though intending to land at an altitude well above the surface. For example, in a
situation where a current altimeter setting is not available and there are few visual cues, this altitude might be 200 feet above the surface. Landing preparation
should include completion of the landing checklist and extension of flaps as recommended by the manufacturer.
The objective is to have the seaplane ready to contact the water soon after it reaches the target altitude, so at approximately 200 feet above the surface, the
pilot should raise the nose to the attitude normally used for touchdown, and to adjust the power to provide a constant descent rate of no more than 150 feet per
minute at an airspeed approximately 10 knots above stall speed. The pilot should maintain this attitude, airspeed, and rate of descent until the seaplane
contacts the water. Once the landing attitude and power setting are established, the airspeed and descent rate should remain the same without further
adjustment, and the pilot should closely monitor the instruments to maintain this stable glide. Power should only be changed if the airspeed or rate of descent,
deviate from the desired values. The pilot should not flare, but let the seaplane fly onto the water in the landing attitude.
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03/17/2015 1430 CST Regis# N9755
Acft Mk/Mdl GRUMMAN ACFT ENG COR-SCHWEIZER Acft SN 1250
Opr Name: OLD RIVER APPLICATORS LLC
New Roads, LA
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba: OLD RIVER APPLICATORS
0
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: SPR
Events
2. Maneuvering - Loss of engine power (partial)
Narrative
On March 17, 2015, about 1430 central daylight time, a Grumman G-164A airplane, N9755, conducted a forced landing following a partial loss of engine power
near New Roads, Louisiana. The commercial pilot, the sole occupant, received minor injuries. The airplane was substantially damaged. The aircraft was
registered to a private individual and operated by Old River Applicators LLC, under the provisions of 14 Code of Federal Regulations Part 137 as an aerial
application flight. Visual meteorological conditions prevailed for the flight, which operated without a flight plan.
According to initial information obtained by the Federal Aviation Administration, as the pilot was maneuvering to commence an aerial application run, smoke
from the engine entered the cockpit followed by a loss of engine power. The pilot then conducted a forced landing to a field; the airplane nosed over on landing.
Substantial damage was sustained to the vertical stabilizer.
The airplane was retained for further examination.
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05/23/2014 1300 EDT Regis# N8890L
Acft Mk/Mdl GRUMMAN AMERICAN AVN. CORP. AA1B Acft SN AA1B-0390
Eng Mk/Mdl LYCOMING O-235-C2C
Acft TT
Opr Name: WARRIORS TO WINGS AERO CLUB
Opr dba:
2258
Chester, SC
Apt: N/a
Fatal
2
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Events
2. Enroute-cruise - Fuel exhaustion
Narrative
HISTORY OF FLIGHT
On May 23, 2014 about 1300 Eastern Daylight Time, a Grumman American AA1B, N8890L, was substantially damaged when it impacted several trees and
terrain near Chester, South Carolina. The airplane had departed from Columbus County Municipal Airport (CPC), Whiteville, North Carolina, about 1130 and
had an intended destination of Heaven's Landing (GE99), Clayton, GA. Day visual meteorological conditions prevailed and no flight plan had been filed. The
commercial pilot and passenger were fatally injured. The airplane was operated by Warrior to Wings Aero Club and the personal flight was conducted under the
provisions of Title 14 Code of Federal Regulations Part 91.
Review of Federal Aviation Administration (FAA) radar data revealed that the accident flight was first detected at 1137:49, northwest of CPC, at an altitude of
1,200 feet above mean sea level (msl). The flight flew northwest and then turned towards the west south west. The last radar data near CPC was recorded at
1155:25 at 2,500 feet msl. Radar data obtained from Charlotte Approach Control revealed the accident airplane east of the accident location at 1301:00 at
2,600 feet msl. The last radar data was recorded at 1306:36 at 2,300 feet msl, near the accident location. No further radar data was located.
According to FAA and pilot records, the pilot held a commercial pilot certificate with ratings for airplane single-engine land, multiengine land, helicopter and
instrument airplane which was issued on October 23, 2013, issued on the basis of his military ratings. He held an FAA third-class medical certificate, issued
June 6, 2011, which was issued with no limitations. At the time of the medical examination the pilot reported zero (0) total hours of flight experience and zero
(0) hours of flight experience in the 6 months prior to the medical certificate. The pilot's logbook was located within the wreckage. The last recorded entry was
dated May 18, 2014 and indicated a pattern work flight at Albert J. Ellis Airport (OAJ), Jacksonville, North Carolina. Including that entry the total recorded flight
time was 37.6 flight hours and included 9.5 flight hours in the accident aircraft make and model. According to information provided by the United States Marine
Corps (USMC), the pilot had 243.7 total flight hours with the USMC and included 78.1 hours in a single-engine propeller airplane. There were no entries that
indicated the pilot had ever flown to GE99.
According to FAA and aircraft maintenance records, the airplane was issued an airworthiness certificate on April 18, 1974, and was registered to Warriors to
Wings Aero Club on April 13, 2013, following it purchase on April 12, 2013. It was a two-place, all-metal, low-wing monoplane with fixed-tricycle landing gear. It
was powered by a Lycoming O-235-C2C 108-hp engine that had accrued 2,257.6 hours since new, with no entry of an overhaul recorded in any of the
logbooks. It was also driven by a McCauley propeller 1A105 SCM 7153. According to the maintenance records, the last recorded tachometer entry was 2,254.4
flight hours, which correlated to the most recent 100-inspection entry for both the airplane and engine. The tachometer was located at the accident scene and
indicated 2,257.6 hours.
The airplane's fuel system utilized a tubular main wing spar comprised of a two-cell fuel tank (one cell in each wing). Each fuel cell held 12 gallons of fuel, of
which, 11 gallons were considered usable. Fuel quantity was indicated by vertical sight gauges on the left and right cabin walls, each sight gauge corresponded
to the respective side fuel cell.
The 1255 recorded weather observation at Chester Catwaba Regional Airport (DCM), Chester South Carolina, located 8 miles to the northeast, included wind
from 310 degrees at 8 knots, variable between 250 degrees and 350 degrees, visibility 7 miles, clear skies, temperature 32 degrees C, dew point 16 degrees C;
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barometric altimeter 30.03 inches of mercury.
The airplane was found on May 26, 2014, in a wooded area within a 500-acre private hunting club, located at 34 degrees 40.21 North latitude and 081 degrees
17.01 West longitude, approximately 400 feet prior to a clearing. The clearing was about 500 feet long and 200 feet wide with the longest section oriented in a
southwest to northeast direction. The main wreckage was located inverted at an elevation of 484 feet msl. The debris was located within a compact area. The
impact line from the first tree strike to the final resting location was about 35 feet in length and on a decent angle of about 38 degrees. The engine remained
attached to the airplane with the engine mounts, lines, and cables, and was co-located with the main wreckage. The wreckage debris path was oriented on
273-degree heading from the initial tree strike to the main wreckage.
The area around the accident location was devoid of fuel smell; however, there was little evidence of blight on a few leaves in the surrounding foliage in the
immediate vicinity of the impact location. However, the area of blight was not widespread in circumference.
Fuselage
The fuselage assembly, right wing, engine and propeller were located inverted at the base of tree. The left wing was located immediately underneath the
wreckage at rest.
The top of the occupant compartment remained intact aft of the windscreen, the windscreen was fractured into multiple pieces. The right side of the airplane
was cut by first responders to facilitate recovering of the occupants. The nose gear was impact separated and was located about 15 feet forward of the
wreckage, and was one of the furthest pieces from the airplane.
Continuity to all flight control surfaces was confirmed from the T-bar at the base of the pilot control yoke to their associated control surface; except for the left
aileron and flap. Both of the left wing flight controls were confirmed from the T-bar to the impact fracture point at the wing root and from that fracture point to the
aileron and flap.
The flap indicator and associated flaps were in the up (retracted) position.
The fuel selector indicator was found between the left and right fuel tank detents. The fuel selector valve face plate had a mark on the plate in the same
location between the left and right tank detent. The valve was removed from the airframe and the line fittings were removed to examine the position of the
orifices. The fuel line that provided fuel to the engine and the fuel line associated with the left fuel tank were both found in the open position. The line
associated with the right fuel tank was found in the closed position. Manipulation of the selector valve revealed limited movement within a 30 degree arc and
the valve was disassembled. The Teflon plunger was found fractured approximately one-fourth of the way from the bottom of the plunger; the separated piece
was found loose in the bottom of the valve body. The damage to the plunger was consistent with impact damage.
The airplane's ignition key was found selected to the "BOTH" position.
Vertical Stabilizer
The empennage assembly remained attached to the fuselage. However, the rudder and elevator were impact-damaged and remained attached to the
empennage assembly via the cables. Both the elevator and rudder indicated impact damage and multiple fracture points. The left elevator had impact and
scrape marks on the upper side of the surface. The marks were associated with a scrape mark found on the tree that it came to rest against. The tree scrape
mark began about 25 feet agl on the tree trunk and ceased about 5 feet agl. The rudder remained attached to the elevator assembly. The rudder and elevator
cables were in place, and remained in the pulley groove. The cables remained secured and were continuous to the rudder bar and the T-bar in the cockpit. The
rudder stops were in place and secure.
The vertical stabilizer was separated, but remained in the immediate vicinity. The separation was consistent with impact damage.
Left Wing
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The left outboard fiberglass wingtip section, was separated and found along the debris path. The fuel cap remained secure and in place and the fuel tank was
devoid of fuel. The output from the fuel tank to fuselage was impact separated. The left flap inboard 21 inches was impact separated; however, was in the
immediate vicinity of the left wing. The leading edge exhibited crush damage in the aft and slight positive direction. The aileron and flap control tube was
fractured at the wingroot due to tensile overload. The left main gear remained attached to its attach point.
Right Wing
The right outboard fiberglass wingtip section, was separated and found along the debris path. The fuel cap remained in place; however, it had been opened by
first responders during occupant recovery. The cap was observed loose on the filler neck and exhibited no positive detent at the fuel cap stop and was unable
to seal on the filler neck. The fuel tank was devoid of fuel. The wingtip, which was light blue in color, exhibited staining, similar in color as 100LL fuel. The
outboard section of the leading edge exhibited crush damage in the aft and positive direction. The inboard 25 inches, from the wingroot exhibited aft impact
damage in the slight positive direction. The right main gear remained attached to its attach point.
Engine
The engine remained attached to the airframe via the mounts, cables and wires. The propeller remained attached to the propeller hub which remained attached
to engine. The carburetor remained attached to the engine. Fractures were noted at the attach point for the oil sump as well as radial at the throttle plate shaft.
The carburetor was disassembled and trace amounts of a blue fluid observed; however, the carburetor bowl was devoid of fluid. The metal floats remained
attached, operated by hand, and exhibited no damage consistent with hydraulic deformation. The fuel inlet screen was removed and was free of debris. The
carburetor heat gate operated smoothly with no abnormalities noted. The throttle plate exhibited impact damage but was able to operate. The engine driven
diaphragm fuel pump was hand actuated and furnished suction and compression; however, it was devoid of fuel. The spark plugs were removed and appeared
gray in color with normal wear and appeared to be recently cleaned. The engine was rotated utilizing a turning tool inserted at the vacuum drive pad and
continuity was confirmed through to the propeller flange. Thumb suction and compression was confirmed on all four cylinders. The cylinders were examined
utilizing a lighted borescope and all cylinders were normal in wear with no noted defects. The magnetos were removed and when spun utilizing a cordless drill,
spark was observed on all 8 leads. The engine driven fuel pump was removed and disassembled the diaphragm was normal and free of debris, no
abnormalities were noted. The oil dipstick was absent but oil was present throughout the engine.
The McCauley two bladed propeller, remained attached to propeller hub, and exhibited no S-bending or leading edge damage. However, the propeller flange
had aft crushing damage, consistent with impact damage, around the circumference. One propeller blade had an aft bend about 7 1/4 inches from the outside
diameter of the hub and chordwise scratches were observed on the backside (as viewed from the pilot seat). The outboard approximate 4 inches of the other
propeller blade exhibited a slight bend at of the blade tip but otherwise was unremarkable and indicated no leading edge damage. The propeller signatures were
consistent with no rotation at the time of the accident.
ELT
The ELT was co-located with the airplane; however, was impact-separated from the airframe and the antenna; it was located on the ground immediately
underneath the tail section. The unit had an "ON/OFF/ARM" switch was found in the "OFF" position. The investigation could not determine if the ELT was
deactivated by first responders or was not in the "ARM" or "ON" position at the time of impact. However, there were no reports of ELT signals being detected in
the area from the day of the accident until the airplane was located.
An autopsy was performed on the pilot on May 27, 2014, by York Pathology Associates, Rock Hill, South Carolina, as authorized by the Chester County
Coroner's Office. The cause of death was reported as "blunt force trauma with sudden deceleration injuries."
Forensic toxicology was performed on specimens from the pilot by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The
following were the findings of the toxicological testing:
- Acetone detected in Blood
- 40 (mg/dL, mg/hg) Ethanol detected in Blood
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- 24 (mg.dL) Ethanol detected in Urine
- NO ETHANOL detected in Brain
- 8 (mg/dL, mg/hg) Isopropanol detect4ed in Blood
- 12 (mg/dL, mg.hg) N-Propanol detected in Blood
- N-Propanol detected in Urine
- 33.8 (ug/ml, ug/g) Salicylate detected in Urine.
Additionally, putrefaction (which consists of the post-mortem creation of ethanol) was noted as yes.
According to the 2008 edition of Drug Facts and Comparisons, Salicylate is a metabolite of aspirin, an over-the-counter anti-inflammatory medication to treat
aches and pains, as an antipyretic to reduce fever. According to the FAA's Aerospace Medical Research database, the therapeutic range of Salicylate 20 -250
ug/ml.
A receipt was located with the pilot's name imprinted and the airplane registration number on it showing 11.92 gallons of 100 LL fuel was purchased at 1121 on
the day of the accident at CPC.
Owner's Manual
According to the Gulfstream Aerospace "Owner's Manual," Chapter 5 "Performance" the airplane's engine would consume between 4.5 and 6.5 gallons per
hour, at 2,500 feet msl depending on the rpm utilized. The manual further states that, "Actual performance will vary from standard due to variations in
atmospheric conditions, engine and propeller condition, mixture leaning technique, and other variables associated with the particular performance item." The
performance further provided "notes" when utilizing the performance chart; one of the notes included "Fuel consumption is for level flight with mixture leaned. In
the "Performance-Specifications" section, the manual cruise power setting was listed as 75 percent at 3,000 feet.
According to the Lycoming Operator's Manual, the burn rate, depending on percent of power could be as much as 10.7 gallons per hour. However, at 75
percent power, which correlated to 2,350 rpm, the fuel flow would be about 7.3 gallons per hour.
Electronic Data
An Apple iPad was located in the airplane and sent to the NTSB Vehicle Recorder Laboratory. An exterior examination revealed the device had sustained
extensive structural damage. The unit was disassembled and the internal board was removed. The internal board was sent to a chip-level recovery service for
further recovery. The recovery service stated, "due to the severity and low-level nature of the failure in this case, no data was recoverable."
Flight Plan
An undated flight plan was located in the wreckage the flight plan showed a proposed departure time from Wilmington International Airport (ILM), Wilmington,
North Carolina as "1300Z." The flight plan indicated a route of flight as direct to GE99; however, a handwritten note indicated "KHVS refuel top to 20 gal." The
flight plan further indicated a true airspeed of 100 knots, a cruising altitude of 6,500 feet msl, an estimated time enroute of 2 hours 45 minutes, and fuel on
board as 3 hours and 30 minutes. The flight plan listed the accident pilot as the pilot for the flight.
According to flight planning software, the direct routing from CPC to GE99 was on a 288-degree course and was 238.1 nautical miles. Reviewing that route of
flight revealed that the accident location was along the course and was 129.2 nautical miles from the departure airport.
According to a representative of Lockheed Martin Flight Service Station, "no weather briefing or flight plan services were found" for the accident airplane for the
days around the departure date.
Flying Club
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According to a representative of the flying club that owned the airplane, the club rented the airplane to the members at a "dry rate." They further reported that
the pilot member was required to purchase fuel themselves and that the flying club did not provide fuel for the airplane. It was further reported that the plane
would have had a minimum of 30 minutes of fuel prior to the flight as that was the regulation required minimum fuel for a visual flight rules flight. They further
reported that the accident pilot had planned to depart the home base airport and land at another airport to purchase fuel prior to continuing on to the intended
destination.
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03/18/2015 1900 EDT Regis# N99HB
Acft Mk/Mdl LANSHE AEROSPACE LAKE 250
Acft SN 236
Eng Mk/Mdl LYCOMING TI0-540 SER
Opr Name: CHRISTINE C MOUTERDE
Fernandina Beac, FL
Apt: Fernandina Beach Municipal FHB
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
1
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: STN
Events
3. Landing-flare/touchdown - Landing gear not configured
Narrative
On March 18, 2015, about 1900 eastern daylight time, a Lanshe Aerospace Lake 250, N99HB, operated by a private individual, was substantially damaged
while landing at Fernandina Beach Municipal Airport (FHB), Fernandina Beach, Florida. The private pilot was seriously injured. The personal flight was
conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the flight
that originated from Georgetown County Airport (GGE), Georgetown, South Carolina, about 1700.
Several witnesses at FHB reported that the airplane performed a go-around during its first approach, which was to runway 4. During the second attempt, the
airplane approached runway 13, a 5,152-foot-long asphalt runway. The airplane touched down more than halfway down runway 13 and bounced several times,
before coming to rest near the end of the runway.
The pilot reported to a responding law enforcement officer that the airplane encountered windshear.
Examination of the airplane by a Federal Aviation Administration inspector revealed that the landing gear handle was in the "UP" position and the landing gear
was retracted. The inspector also noted substantial damage to the lower fuselage.
The recorded weather at an airport located about 14 miles south of the accident site, at 1852, included wind from 360 degrees at 11 knots, gusting to 19 knots.
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03/29/2015 1245 PDT Regis# N381BA
Acft Mk/Mdl LET L23 - NO SERIES-NO S
Opr Name: CIVIL AIR PATROL INC
Page 107
Acft SN 018801
Los Alamitos, CA
Apt: Los Alamitos Aaf SLI
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire: NONE
All Rights Reserved
06/17/2014 1230 EDT Regis# N535TJ
Cherryville, NC
Apt: Private Airstrip N/A
Acft Mk/Mdl MAULE M4-220C
Acft SN 2092C
Eng Mk/Mdl FRANKLIN 6A-350-C1
Acft TT
Fatal
Opr Name: JOHNSON KIRKLAND L
Opr dba:
2157
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Events
Narrative
On June 17, 2014, about 1230 eastern daylight time, a Maule M4-220C, N535TJ, was substantially damaged during landing at a private grass strip near
Cherryville, North Carolina. The certificated private pilot and passenger were not injured. The airplane sustained substantial damage to the fuselage. Visual
meteorological conditions prevailed and no flight plan was filed for the flight. The airplane was registered to and operated by a private individual under the
provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. The flight originated at Shelby-Cleveland County Regional Airport (EHO),
Shelby, North Carolina, around 1200.
According to the pilot, the purpose of the flight was to refuel the airplane at EHO and then return to the private grass strip. The pilot indicated that during
touchdown on the grass strip the main landing gear collapsed. He also stated that the landing "seemed no harder" than any other landing. The airplane came to
rest in taller grass at the edge of the grass strip and the occupants egressed without incident.
The pilot reported that the most recent annual inspection was performed on February 14, 2014, and at that time the airplane had accumulated 2157 total flight
hours.
The pilot held an airline transport pilot certificate with a rating for airplane multiengine land, and a commercial pilot certificate with ratings for single-engine land,
single-engine sea, and gliders. In addition, he held a flight instructor certificate with ratings for airplane single and multiengine land, and instrument airplane. His
most recent Federal Aviation Administration (FAA) first-class medical certificate was issued on March 3, 2014. The pilot reported approximately 23,000 total
hours of flight experience, of which 65 of those hours were in the accident airplane make and model.
According to a FAA inspector, the fuselage sustained substantial damage near the main landing gear attach points. A postaccident examination of the damaged
main landing gear assembly was performed by removing the landing gear fairings. The landing gear strut consisted of an "A" frame assembly and an oleo strut
that extended from the fuselage to the gear hub. Both tubes of the "A" frame assembly on each main landing gear exhibited buckling about mid length and both
of the main landing gear struts were bent in the positive direction. There was no corrosion noted on the mounting hardware, landing gear attach mounts, or main
landing gear assembly of the airplane. No other anomalies were noted with the airplane that would have precluded normal operation prior to the accident.
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Accident Rpt# WPR13FA169
03/28/2013 1119 MST Regis# N6018X
Wikieup, AZ
Apt: N/a
Acft Mk/Mdl MOONEY M20A
Acft SN 1606
Eng Mk/Mdl LYCOMING O-360-A1D
Acft TT
Fatal
Opr Name: VIDSON CHAN
Opr dba:
3761
1
Ser Inj
2
Aircraft Fire: NONE
Events
Narrative
HISTORY OF FLIGHT
On March 28, 2013, about 1119 mountain standard time, a Mooney M20A, N6018X, made an off airport forced landing near Wikieup, Arizona. The pilot/owner
was operating the airplane under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. The private pilot and one passenger sustained serious
injuries; one passenger sustained fatal injuries. The airplane sustained substantial damage from impact forces. The cross-country personal flight departed
Sedona, Arizona, with a planned destination of Shafter, California. Visual meteorological (VMC) conditions prevailed, and no flight plan had been filed.
The Federal Aviation Administration (FAA) reported that the pilot contacted Albuquerque Air Route Traffic Control Center (ABQ ARTCC) at 1028:07 requesting
visual flight rules flight following. The estimated position was about 15 miles west of Sedona at 8,600 feet msl. At 1106:01, the pilot informed the controller that
the engine lost oil pressure, and he needed vectors to the closest airport. The controller provided vectors to Bagdad airport (elevation 4,183 ft), and at 1109:30,
the pilot advised that the airplane was losing altitude. The controller contacted another airplane in the area at 1111:16, and requested that airplane provide
assistance. At 1113:28, the accident airplane was 5 miles from Bagdad at 6,600 feet. At 1115:56, the pilot stated that the engine was running rough, then within
1 minute that there was smoke in the cockpit, and he was shutting the engine off. The controller advised the pilot to look for an open field, clean the airplane
up, and shut the fuel off. The pilot advised that he could see an open area. The last transmission from the pilot was at 1118:07, when he responded to the
assist airplane that he had a cell phone; although the number was not recorded, the assist airplane's readback was recorded at 1118:49.
The pilot made a forced landing in rough terrain. The pilot and front seat passenger were pinned in the wreckage. His son in the back seat sustained a serious
injury, but was able to egress from the airplane.
A witness was camping about 1 mile from the accident site. He stated that the airplane flew about 300-400 feet over him, and the wings were rocking about 3-4
feet as if the pilot was waving to him. He said that the engine was silent, but he could not recall if the propeller was stopped or turning. He noted that the
landing gear was down, and he did not observe any smoke or fluids emanating from the airplane. He did not hear the crash, and had observed airplanes flying
low over this area on previous occasions.
A review of FAA airman records revealed that the 48-year-old-pilot held a private pilot certificate with a rating for airplane single-engine land. The pilot held a
third-class medical certificate issued on February 22, 2013, with the limitation that it was not valid for any class after February 22, 2014.
No personal flight time records were received from the pilot. The 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, Oklahoma. The pilot reported on his medical application that he
had a total time of 156 hours with 5 hours logged in the previous 6 months. A logbook excerpt recorded a biennial flight review and FAR 61.31(e) endorsement
for operating a complex airplane on October 11, 2011.
The airplane was a Mooney M20A, serial number 1606. A review of the airplane's logbooks revealed that the airplane had a total airframe time of 3,761.8 hours
at the last annual inspection dated October 3, 2012. The tachometer read 1,048.8 hours at the last inspection. The tachometer read 1,053.8 hours at the last
recorded maintenance (an oil change) on February 1, 2013; it read 1,064.37 hours at the accident scene.
The airplane was not equipped with shoulder harnesses.
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The engine was a 180 horsepower Lycoming O-360-A1D, serial number L-9731-36A. Total time on the engine at the last annual inspection was 3,739.6 hours,
and time since major overhaul was 1,179.8 hours.
The NTSB investigator-in-charge (IIC) examined the wreckage at the accident scene.
The airplane came to rest upright in mountainous terrain on the crest of a descending ridge. The first identified point of contact (FIPC) was on the upslope of
the ridge; it was an ocotillo cactus plant with the top branches broken off about 4-6 feet above the ground. There was a ground scar about 15 feet left and
upslope of the cactus. About 12 feet forward and 10 feet to the left of the FIPC was a 1-foot by 1-foot piece of the outboard leading edge of the left wing, which
contained the red navigation light.
Twenty feet from the FIPC was the principal impact crater (PIC) ground scar, which was about 5 feet wide and 10 feet long. A damaged bush was about 10 feet
right of the PIC.
The main wreckage was about 60 feet from the FIPC on the debris path centerline.
The last major piece of wreckage was the pilot's window at 65 feet 4 left.
There was black viscous fluid on the belly of the fuselage all the way to the tail skid and end of the tail cone. The ground underneath the fuselage had some
black liquid stains as well.
The belly of the airplane was crushed up and aft from the spinner to the engine compartment and through the bottom of the cabin area. The nose gear was
crushed up and aft into the airframe.
The Johnson bar landing gear operating handle was in the vertical position with the locking arm in place.
The ignitions switch was in the off position.
Both control yokes had the hand grips intact.
TESTS AND RESEARCH
The IIC and investigators from the FAA and Lycoming examined the wreckage at Air Transport, Phoenix, Arizona, on March 30, 2013.
A full report is contained within the public docket for this accident.
Engine
The top spark plugs were removed; all center electrodes were circular, and clean with no mechanical deformation. The spark plug electrodes were gray, which
corresponded to normal operation according to the Champion Aviation Check-A-Plug AV-27 Chart.
The engine crankshaft would not rotate.
The propeller was removed and a non-Lycoming manufactured shim was located between the face of the propeller hub and the crankshaft propeller flange that
varied in thickness. From a review of the airplane's logbooks, it could not be determined who manufactured and installed the shim, or when it was installed.
The magnetos were manually rotated, and both magnetos produced spark at all posts.
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A visual inspection of the engine revealed a fracture that emanated from the top of the cam follower area of the crankcase at the number two cylinder.
No oil registered on the dipstick, and a burning smell emanated from the filler tube. The oil filter was removed and cut open; the filter element displayed
magnetic and bronze material impregnated in the element. The oil sump was removed, and approximately 1/2 quart of a black fluid was observed in the bottom;
the liquid had a burnt smell. There were numerous pieces of debris in the oil pan including parts of the number two connecting rod end cap, beam, and pieces
of rod bolts and nuts along with plasticized rod bearing material. The oil suction screen was removed, and it was obscured with magnetic material.
All cylinders were removed from the crankcase. All cylinder skirts were impact damaged, and pry bars were required to remove the cylinders. The cylinder
bores did not exhibit scoring or scraping. All pistons displayed normal carbon deposit on their tops.
The crankcase was disassembled. It was noted that the two crankcase halves were coated with a substance consistent with automotive Permatex gasket
sealer on the mating surfaces.
The number one connecting rod moved freely on its journal.
The number two piston remained in the cylinder; its connecting rod beam fractured and separated at the crankshaft rod journal. The fracture surface sustained
heavy mechanical damage. The connecting rod cap, saddle, nuts and bolts separated at the connecting rod.
The crankshaft rod journal for the number two connecting rod beam was thermally damaged and scored. The number two connecting rod bearing was not in
place.
The number three connecting rod was thermally seized to the crankshaft.
The number four connecting rod was moveable, but thermal and impact damage was evident in the area of the connecting rod bearing.
The crankshaft was dimensionally examined using V blocks and a dial indicator. The flange was ~0.87 out of round. The manufacturer's limits for a run-out (out
of round) were 0.002 inch minimum and 0.005 inch maximum.
Materials Laboratory Examinations
The crankshaft, the shim, and rod end nut pieces were sent to the NTSB Office of Research and Engineering Materials Laboratory for examination. A full report
is in the public docket.
The main journals were labeled M1, M2, and M3, and the connecting rod journals were labeled C1, C2, C3, and C4 for reference. The crankshaft journals
showed varying levels of heat tinting and scoring. Journals C2 and C4 had the highest levels of damage with smeared deposits and scoring.
The edges of the propeller flange showed numbers marked in black ink at several of the attachment bolt holes. Numbers 3, 4, 5, and 6 were marked in
sequence next to four of the attachment bolts moving counterclockwise. No similar marks were observed adjacent to the other two attachment bolt locations.
For reference in this report, the bolt hole corresponding to the number 1 position was referenced as the 12 o'clock position.
The shim was removed from the forward face of the crankshaft. Black ink markings were observed on the forward face of the crankshaft. Asterisks were
marked at the 5 o'clock and the 11 o'clock positions. IN was marked at the 1 o'clock position, and OUT was marked at the 7 o'clock position.
The positions of the main journals and their orientation relative to the forward face of the propeller flange were measured. Software was used to analyze the
geometry of the position measurements. The positions of the journal faces were determined along the length of each main journal at multiple locations around
each circumference. The position of the flange forward face was also determined by probing around the circumference. According to the analysis of the
measured data, the axes of main journals M2 and M3 were oriented within 0.0023 degree of each other. However, the axis of journal M1 was angled 0.097
degree relative to the axis of journal M3. The forward end of the journal M1 axis was tilted toward the 10 o'clock position relative to the axis of journal M3.
The normal vector for the forward face of the propeller flange was angled relative to the journal M3 axis. The angle between the journal M3 axis and the flange
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normal was 0.726 degree. The orientation of the flange normal relative to the journal M3 axis was such that the flange was bent aft at the 4 o'clock position and
bent forward at the 10 o'clock position.
The propeller flange had a nominal diameter of 6 inches. With the flange tilted 0.726 degree relative to the plane perpendicular to the journal M3 axis, the outer
edge would be displaced forward up to 0.038 inch and aft up to 0.038 inch relative to the center of the flange.
The shim was flat on the aft face, and had a concentric polygon-shaped step pattern on the forward face. Thickness varied across the shim; the thinnest
location was at the 11 o'clock position, where the thickness measured 0.0035 inch. The thickest location was located at the 4 o'clock position, where the
thickness measured 0.0884 inch.
Maintenance Logbook Information
A logbook entry on November 21, 2006, indicated that the original Lycoming engine was sent to a repair facility for a propeller strike inspection.
An entry in the logbooks on March 26, 2007, indicated that the airplane had been repaired after a gear-up landing. Total time on the airframe was 3,661.42
hours at a tachometer time of 936.42 hours.
A logbook entry dated December 11, 2008, recorded a 100-hour inspection by an Airframe and Powerplant (A&P) mechanic. It noted replacement of the original
engine with the accident engine. Total time on the accident engine was 3,598.8 hours, and time since major overhaul was 1,039.0 hours. The propeller was
replaced with a Hartzell HC-92WF-8D, serial number 8781. The propeller total time was 2,486.0 hours. It had been overhauled on September 18, 2002, and had
21.0 hours since overhaul. This entry noted that one belly skin was replaced, the wheel well doors were adjusted, and one landing gear bolt was replaced.
A mechanic with Inspection Authorization (IA) recorded an annual inspection on December 13, 2008. The entry recorded that the total time on the airframe was
3,680.0 hours, and the tachometer read 958.0 hours.
An entry for April 2, 2010, noted an annual inspection at a tachometer time of 963.0 hours.
A review of FAA registration information indicated that the accident pilot purchased the airplane in January 2011.
An entry dated April 14, 2011, noted a 100-hour inspection by an A&P mechanic. The tachometer time was 965.1 hours.
An entry dated June 1, 2011, recorded an annual inspection by an IA. The tachometer time was 978.7 hours with a total time of 3,700.7 hours.
The logbooks contained an entry for an annual inspection on October 3, 2012. Total time in service was 3,761.8 hours; the tachometer read 1,048.8 hours.
There were no logbook or Form 337 entries to indicate when the nonstandard shim was manufactured, installed, or who made it.
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03/04/2015 413 EST
Regis# N66BB
Norfolk, VA
Acft Mk/Mdl MOONEY M20F
Acft SN 22-1253
Rpt Status: Prelim
Eng Mk/Mdl LYCOMING IO-360A1A
Acft TT
Fatal
Opr Name: BEAUCHAMP JAMES W
Opr dba:
948
3
Apt: Norfolk Intl ORF
Ser Inj
0
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: STN
Events
1. Approach-IFR final approach - Controlled flight into terr/obj (CFIT)
Narrative
On March 4, 2015, about 0413 eastern standard time, a Mooney M20F, N66BB, was substantially damaged when it impacted trees and terrain while conducting
an instrument approach to Norfolk International Airport (ORF), Norfolk, Virginia. The private pilot and two passengers were fatally injured. Dark night instrument
meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed and active for the flight, which originated from Palatka Municipal
Airport (28J), Palatka, Florida, about 2357 on the preceding day. The personal flight was conducted under the provisions of 14 Code of Federal Regulations
Part 91.
According to the owner of the airplane, the pilot and two friends had borrowed the airplane and departed from its home base of Suffolk Executive Airport (SFQ),
Suffolk, Virginia on February 25. The group flew to Key West International Airport (EYW), Key West, Florida, and on the evening of March 2, at 1916, the pilot
contacted Flight Service in order to file two IFR flight plans for the return trip to SFQ. The first flight plan requested GPS direct routing from EYW to 28J, while
the second requested GPS direct routing from 28J to the Brunswick, Georgia (SSI) very high frequency omni-range (VOR), then direct to SFQ. For that leg, the
pilot declared an estimated time enroute of 3 hours and 30 minutes, with an estimated 5 hours of fuel onboard. The flight subsequently departed EYW about
2030 and arrived at 28J about 2240.
According to self-service fueling records, while at 28J the pilot purchased 31 gallons of 100LL aviation fuel at 2244. The flight subsequently departed 28J at
2357, enroute to SFQ. According to preliminary air traffic control (ATC) voice communication and radar data provided by the Federal Aviation Administration,
the pilot was cleared to execute the RNAV (GPS) RWY 22 instrument approach to SFQ at 0307. At 0324, the pilot contacted ATC and advised that he was
executing a missed approach, and that he would like to divert to ORF. The controller subsequently provided the pilot with radar vectors, and at 0337, issued the
pilot a clearance for the ILS RWY 23 instrument approach to ORF.
During the subsequent approach, ATC provided the pilot with several altitude and course corrections, and about 0349, canceled the previously-issued approach
clearance. The pilot then advised ATC that he would like to attempt the approach a second time, and ATC provided radar vectors for the second approach
attempt. When asked by ATC if he was experiencing any equipment problems the pilot stated, "It's literally a washing machine as soon as we go through the
cloud deck, the cloud deck's at 1,200 feet, before that everything's very easy, but once we get to 1,200 feet it's a washing machine." At 0354, the pilot advised
ATC, "Six six bravo bravo is actually experiencing moderate turbulence, there are things floating around the cabin." About one minute later, ATC cleared the
pilot for a second ILS approach to runway 23 at ORF.
After the approach clearance was issued, the pilot advised ATC, "we're having a lot of precession with our gyros, I don't know if the turbulence disrupted it, if at
all possible radar vectors would be appreciated on the glide slope, it's a very very wild ride." When asked to clarify if he was requesting a no-gyro approach
from the controller, the pilot stated that the instrument just needed to be periodically re-aligned during the descent and that some radar feedback would be
adequate. Just prior to establishing the airplane on the final approach course, the pilot advised ATC that the airplane's indicated airspeed was 105 knots, while
its GPS-derived groundspeed was 32 knots.
At 0403, while inbound to the final approach fix, ATC again offered the pilot standard-rate-turn, no-gyro radar vectors. The pilot accepted the offer and advised,
".we're having a real problem with precession." At 0405, the pilot advised ATC that the airplane had an estimated «-hour of fuel onboard. The controller
provided the pilot with radar vectors and updates on the current weather conditions as the airplane proceeded along the approach path. At 0413, the airplane
was about 0.7 nautical miles north of the runway 23 threshold, at a reported altitude of 200 feet, and a ground track oriented toward the runway threshold.
About that time, the pilot advised ATC that he had the airport in sight, and was subsequently cleared to land. No further radio transmissions were received from
the pilot.
At 0413:21, the airplane began tracking westward, while remaining at an altitude of 200 feet. The airplane's final radar-derived position was recorded at
0413:40, at a reported altitude of 200 feet, on a track oriented roughly 245 degrees magnetic. That position was located about 2,800 feet northwest of the
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runway 23 threshold. ATC subsequently attempted to contact the pilot several times after radar contact was lost, to no avail, and then contacted first
responders to begin coordinating an accident response.
The accident site was located about 2,300 feet northwest of the ORF runway 23 threshold. The initial impact point was identified as a tree with numerous
branches broken from its top, at a height of about 80 feet. The tree was located about 20 feet from the shoreline of Lake Whitehurst. A wreckage path extended
for about 260 feet, on a magnetic heading of 220 degrees. Broken tree branches, paint chips, and small pieces of metal were distributed along the wreckage
path. The main wreckage came to rest inverted at the base of a tree, oriented roughly 210 degrees magnetic. All major components of the airplane were
accounted for at the accident site, and the wreckage did not display any evidence of a pre or post-impact fire. The outboard three feet of both wings were
separated from the airplane, and were found adjacent to the main wreckage. The left wing displayed a concave depression of its leading edge, outboard of the
landing gear, oriented perpendicular to the spar, about 16 inches in diameter. The left fuel tank was ruptured and absent of fuel, and a trace amount of fuel
remained in the right fuel tank. The landing gear were extended while the flaps were retracted. Control continuity was traced though separations consistent with
overload from the cockpit controls to each of the flight control surfaces. The State of Virginia, Office of the Chief Medical Examiner reported that both front seat
occupants were restrained with lap belts. No shoulder restraints were installed. The emergency locator transmitter remained secured to its mount and was
found in the armed position about 36 hours after the accident.
Both of the propeller blades displayed aft tip curling and s-bending. One of the blades exhibited chord-wise scratching and its tip was torn away. A significant
quantity of freshly-cut pine needles and tree branches less than 4 inches in length were found inside the engine cowling on top of the engine. Continuity of the
power and valvetrain were confirmed through rotation of the propeller by hand, and thumb-compression was observed on all cylinders. The spark plug
electrodes exhibited normal wear and were dark gray to black in color. A trace amount of liquid consistent in color and odor with 100LL aviation fuel was found
within the flow divider and fuel servo inlet screen, with no significant debris or other contamination noted. The oil inlet screen and fuel filter element were absent
of metallic debris, with no other significant contamination noted.
A handheld GPS receiver, an instrument panel-mounted engine analyzer, an engine-driven vacuum pump, as well as the heading and attitude indicators were
retained by NTSB for further examination.
The weather conditions reported at ORF at 0420 included winds from 230 degrees magnetic at 20 knots, gusting to 27 knots, 2 1/2 statute miles visibility in
mist, an overcast ceiling at 200 feet, a temperature of 8 degrees C, a dew point of 7 degrees C, and an altimeter setting of 29.92 inches of mercury.
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05/18/2014 959 EDT
Regis# N200DP
Georgetown, DE
Acft Mk/Mdl MOONEY AIRCRAFT CORP. M20K
Acft SN 25-0090
Eng Mk/Mdl CONT MOTOR TSIO-520-NB
Acft TT
Fatal
Opr Name: GRUND JOSEPH R
Opr dba:
3000
0
Ser Inj
Apt: Sussex County GED
1
Aircraft Fire: NONE
Events
1. Approach-VFR pattern final - Loss of engine power (total)
Narrative
HISTORY OF FLIGHT
On May 18, 2014, at 0959 eastern daylight time, a Mooney M20K, N200DP, was substantially damaged when it collided with power lines and terrain following a
total loss of engine power while on approach to Sussex County Airport (GED), Georgetown, Delaware. The airline transport pilot was seriously injured. Visual
meteorological conditions prevailed, and no flight plan was filed for the flight, which departed Woodbine Municipal Airport (OBI), Woodbine, New Jersey, about
0935. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.
The pilot stated that his was one airplane in a flight of four from OBI to GED, where they planned to purchase fuel and have brunch. He estimated the 40-mile
flight would consume approximately 6 gallons of fuel and he estimated there were "15 to 20 gallons" on board at departure. The en route portion of the flight
was flown at 4,500 feet and the pilot entered the airport traffic pattern for landing on runway 04. The downwind leg was extended due to traffic, and while on
downwind, the pilot switched from the left fuel tank to the right fuel tank, lowered the landing gear, moved the propeller lever to "full," completed "landing
checks," and turned to the base leg of the traffic pattern.
According to the pilot, as he turned from the base leg to the final leg of the traffic pattern, he attempted to increase engine power, but "there was nothing there"
and the engine would not advance past 1,000 rpm. He again attempted to increase power with no response from the engine, and switched the fuel selector
back to the left fuel tank. The pilot believed he "had the field made," but the airplane impacted power lines, and came to rest near the airport boundary
The pilot held an airline transport pilot certificate with a rating for airplane multiengine, and a commercial pilot certificate with a rating for airplane single engine
land. His most recent FAA third class medical certificate was issued on April 30, 2011. He reported 5,000 total hours of flight experience, of which 400 hours
were in the accident airplane make and model.
According to FAA records, the airplane was manufactured in 1979. On August 31, 1995, a 305-horsepower Teledyne Continental TSIO-520-NB engine modified
under Supplemental Type Certificate (STC SE022SE) by Rocket Engineering Corporation was installed.
Its most recent annual inspection was completed June 10, 2013, and the airplane had accrued 91 hours since that date. He estimated the airplane had accrued
3,000 total aircraft hours.
According to Rocket Engineering Corporation, the fuel consumption rate during a maximum-power climb was up to 33 gallons per hour. The fuel consumption
rate between an economy-cruise setting and maximum-cruise setting was 15 to 25 gallons per hour.
According to the Mooney M20K Pilot Operating Handbook, the fuel capacity of the airplane was 78.6 gallons, of which 75.6 gallons were usable.
At 0954, the weather conditions reported at GED included a broken ceiling at 7,500 feet, visibility 10 miles, temperature 16 degrees C, dew point 6 degrees C,
and an altimeter setting of 30.22 inches of mercury. The wind was from 010 degrees at 6 knots.
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The wreckage was recovered from the accident site and moved onto GED airport property, where it was secured for examination at a later date. During
recovery, a total of approximately 7 gallons of fuel was recovered, but the exact amounts recovered from each wing tank could not be determined. Examination
of photographs revealed substantial damage to the wings, fuselage, and empennage.
All three propeller blades were damaged, with one blade cut and scored deeply near its root.
The pilot reported that he downloaded the data from the airplane's engine monitor, and stated, ".60 seconds before the propeller stopped, there was no fuel
flow." He added that he probably should have purchased fuel before his departure from OBI, and that if he had it to do over, he would.
On June 25, 2014, the airplane was secured to a flatbed trailer in Georgetown, Delaware. A slave propeller was installed in place of the damaged propeller and
the airplane was serviced with 10 gallons of aviation fuel; 5 gallons in each wing tank. An external battery was connected at the external power plug, and an
engine start was attempted.
The engine started immediately, and was allowed to warm up at 1,000 rpm. The engine was accelerated to 1,500 rpm, and a magneto check was performed
with satisfactory results. The engine was then accelerated smoothly to 2,400 rpm, where it ran without interruption until stopped by the engine controls in the
cockpit.
During the engine run, the fuel selector was switched four times between the left and right tanks, and the engine ran continuously and without interruption each
time.
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05/22/2014 1830 CDT Regis# N428PM
Gulf Shores, AL
Acft Mk/Mdl P&M AVIATION LTD QUIKR
Acft SN 8428
Acft Dmg: MINOR
Eng Mk/Mdl ROTAX 912 ULS
Acft TT
Fatal
Opr Name: WENDELBURG KEVIN R
Opr dba:
182
0
Ser Inj
Apt: Jack Edwards JKA
1
Aircraft Fire: NONE
Events
1. Standing-engine(s) start-up - Powerplant sys/comp malf/fail
Narrative
HISTORY OF FLIGHT
On May 22, 2014, about 1830 central daylight time, a special light sport P&M Aviation QuikR weight shift aircraft, N428PM, was substantially damaged at Jack
Edwards National Airport (JKA), Gulf Shores, Alabama. The airline transport pilot sustained serious injuries. Visual meteorological conditions prevailed for the
personal flight and no flight plan was filed for the local flight. The flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.
According to the pilot's written statement, he performed a preflight inspection of the aircraft and then attempted to start the engine in an area surrounded by
hangars. He applied full choke, set the hand throttle to idle, applied full left foot brake and placed the magnetos in the ON position. After making about four
unsuccessful attempts to start the engine, the pilot moved the choke back and forth and left it about halfway. He introduced a "little bit of right foot throttle" and,
after about four more attempts, the engine started and "immediately" advanced to "takeoff power." The pilot applied full left foot brake, but the aircraft moved
forward at increasing speed. He attempted to keep the aircraft on the taxiway centerline by steering the nose wheel. The pilot also held the control bar with his
left hand and groped the instrument panel with his right hand for the magneto cutoff. He eventually disengaged one of the two magnetos; however, the right
wing of the aircraft impacted the cowling of a parked airplane located to the right of the taxiway centerline. The aircraft spun to the right, impacted a hangar
door, and came to rest.
Postaccident examination of the accident aircraft by a Federal Aviation Administration (FAA) inspector revealed damage to the left wing spar. The parked
airplane also sustained damage to the propeller and nose cowling. Further examination of the engine control system revealed that the foot pedal throttle and
hand throttle both operated smoothly with no binding.
The initial impact point was the cowling of a parked airplane located about 150 feet from the accident pilot's hangar. According to the FAA inspector, the left
wing spar was broken and there was torn cloth on both the left wing and top center sail. All flight control surfaces remained attached to their respective airframe
components, and flight control continuity was traced from each flight control surface to the cockpit. All three carbon fiber propeller blades had separated; blade
A was broken outboard, blade B was broke mid-span, and blade C was broken inboard near the hub.
Further examination took place in a secure hangar at JKA by a representative of the airframe manufacturer under the supervision of a FAA inspector. The
engine case was undamaged and free of oil or fuel leaks. The right throttle foot pedal was operated several times and some abnormal friction was noted;
however, both carburetors opened and closed each time the foot pedal was depressed and released. The hand throttle was also advanced to the ON position
and retarded to the OFF position several times, and during each operation both carburetors opened and closed. During each operation of the hand throttle, the
hand throttle interrupt switch could be heard, which indicated that the solenoid switch was engaging. The hand choke also functioned normally and no binding
or damage was noted.
The foot throttle cable extended from the right foot pedal behind a pod support bracket and to the left foot position along the basetube. Postaccident
examination revealed two snag hazards that caused the foot throttle to remain in the open position. In one example, when the foot throttle was depressed the
throttle cable could be manipulated by hand to snag on a bolt that fastened the pod support bracket to the fuselage. In another example, the foot throttle cable
could be manipulated by hand to snag on the pilot's left foot, which unseated the throttle cable end and caused the foot throttle to stick open.
The pilot held an airline transport certificate with ratings for airplane single and multiengine land. He had accumulated about 12,737 total hours of flight time, of
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which 72 hours were in the accident airplane make and model.
According to the FAA Aircraft Registry, the accident airplane was manufactured in 2009. The special light sport weight-shift-control category aircraft was
equipped with a three-bladed Warp Drive propeller and one Rotax 912ULS model four stroke engine, rated at 100 horse-power. The airplane's most recent
condition inspection was completed on April 1, 2014, and at that time the airplane had accumulated 179.1 total flight hours.
Throttle System
The airplane was equipped with a foot throttle that automatically returned to the CLOSED position, similar to the accelerator in an automobile, and a
friction-dampened hand throttle. The airplane was also equipped with a starter motor solenoid interrupt switch that prevented the engine from starting with the
handle throttle engaged. The throttle cables connected to a splitter, which contained a single piston that was designed to open and close the butterfly valves to
both carburetors when the throttles were moved. The carburetors were originally designed by the engine manufacturer to default to the open position in the
event of a severed cable, but were altered by the airframe manufacturer to spring-shut.
The 1835 recorded weather observation at JKA included wind from 240 degrees at 9 knots, temperature 27 degrees C, and an altimeter setting of 30.09 inches
of mercury.
Starting Instructions
According to the section entitled "6.3 Starting Engine" in the manufacturer's operating instructions:
6.3 Starting Engine
The pilot must always start the engine when sitting in the cockpit with seatbelts secured and helmet worn.
Pre-start checks:
1. Passenger should also be strapped in and briefed.
2. Throttles both working and fully shut (never use the hand throttle for engine control on the
ground).
ú If starter interrupt switch is fitted, starter will not operate unless hand throttle is CLOSED.
Warning: Engine start-up is always a potentially dangerous time. Make sure that you have done all your checks, that you are not disturbed while doing them,
and that you are entirely happy that the aircraft is in a fit state to be started-up. Finally, before start-up, ensure that the aircraft is pointing away from
people/vehicles/buildings etc, and that there are no pets or other animals which could panic after start-up. Double check that the propeller is clear and hand
throttle is closed before starting the engine.
STARTING: check visually again that the propeller area is clear and call "Clear Prop" loudly. Pause. Turn on the key switch, set the contacts to ON, then push
the button in 5 seconds bursts. Release the button as soon as the engine fires. If the engine refuses to start after 5 or 6 attempts, close the controls and switch
OFF the ignition before investigation.
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03/27/2015 1835 CST Regis# N30341
Pine River, MN
Apt: Pine River Regional Airport PWC
Acft Mk/Mdl PIPER J-4A
Acft SN 4-1168
Rpt Status: Prelim
Eng Mk/Mdl CONT MOTOR C85 SERIES
Acft TT
Fatal
Opr Name: WITT JOHN M
Opr dba:
2870
2
Ser Inj
0
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: STN
Events
Narrative
On March 27, 2015, at 1835 central standard time, a Piper J-4A airplane, N30341, collided with the terrain shortly after takeoff from the Pine River Regional
Airport (PWC), Pine River, Minnesota. The private pilot and passenger were both fatally injured. The airplane was substantially damaged. 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, which was not operated on a flight plan. The flight was originating at the time of the accident.
A pilot who had landed at the airport just prior to the accident reported she heard the airplane as it was took off and that it sounded "normal for an older plane."
She stated the airplane was very low above the runway with the wings wobbling back and forth. This witness also stated the ground speed was very slow,
perhaps 20 miles per hour. She stated the wings stopped rocking for a bit, but the airplane remained slow and just above the treeline as it crossed Highway 1 at
the south end of the runway. The witness stated she looked away and heard an unusual noise just before the airplane impacted the ground.
Another witness reported seeing the airplane flying toward the south just after it took off. This witness reported it was very noticeable that the airplane was
"wobbling" back and forth at a low altitude. Once the airplane reached Highway 1, it banked to the left and the nose rose. The nose then descended and the
airplane entered a nose dive to the ground.
The airplane impacted an open field about 1/4 mile from the departure end and 20 degrees to the left of the extended centerline of runway 16. Damage to the
airplane and ground scars indicate the airplane was in a nose down, left wing low attitude when it impacted the terrain.
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Acft Mk/Mdl PIPER J3C 65-65
Opr Name: DAVID HARMON
Page 120
03/01/2015 1235 EST Regis# N717ML
Clermont, FL
Apt: N/a
Acft SN 22411
Rpt Status: Prelim
Acft TT
Fatal
5800
0
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire: NONE
All Rights Reserved
09/10/2014 1309 EDT Regis# N26105
Carrol County, VA
Apt: N/a
Acft Mk/Mdl PIPER J3C 65-65
Acft SN 4051
Eng Mk/Mdl CONTINENTAL A-75-8
Acft TT
Fatal
Opr Name: HEIMOS BERNARD F
Opr dba:
4288
0
Ser Inj
1
Aircraft Fire: NONE
AW Cert: STN
Events
1. Emergency descent - VFR encounter with IMC
Narrative
On September 10, 2014, about 1309 eastern daylight time, a Piper J3C-65 Cub, N26105, was substantially damaged during an emergency landing and
subsequent in-flight collision with trees and terrain near Carroll County, Virginia. The private pilot was seriously injured. Instrument meteorological conditions
prevailed and no flight plan was filed for the flight that originated from Raleigh County Memorial Airport (BKW), Beckley, West Virginia at 1145, and was
destined for Smith Reynolds Airport (INT), Winston Salem, North Carolina. The personal flight was conducted under the provisions of 14 Code of Federal
According to a Federal Aviation Administration (FAA) Aviation Safety Inspector, the airplane crashed in a remote, wooded area, about 40 nautical miles (nm)
west of BKW, at an elevation of about 2,534 feet. Photographs taken by the Virginia State Police revealed that the airplane was intact with the exception of the
right wing which was located in a nearby tree. There were compression wrinkles throughout the wings, fuselage, and empennage. The wings also exhibited aft
crush damage on the leading edge.
After recovering from his injuries, the pilot was interviewed by the NTSB investigator-in-charge on October 29, 2014. The pilot reported that he was flying
across the United States on a month long cross county flight. After he refueled the airplane at BKW, he departed for INT and followed an interstate highway, as
was his custom. About 40 nm from his destination, he encountered some "mist" and descended, but the "the mist got heavier." He then configured the airplane
for an emergency landing on the interstate and descended between two tree lines, but the airplane impacted a tree, fell to the ground and came to rest in a
nose down attitude. The pilot reported that his attention was focused on the interstate and not on the surrounding obstacles. He also remarked that there were
no preimpact mechanical malfunctions or anomalies with the airplane. The pilot stated that his usual method for obtaining weather was by utilizing the Internet
application Foreflight, but did not recall if he retrieved weather prior to departing BKW.
According to a Virginia State Trooper, the pilot reported that he made the decision to land the airplane after the weather abruptly changed to fog.
A witness reported that the weather at the time was "foggy and rainy." He stated that he was driving southbound on the interstate and observed the airplane to
his left on a southerly heading. The airplane appeared to be cruising above the tree tops and "went straight into the trees".
A review of global positioning system data retrieved from an onboard Garmin GPSMAP 296 revealed that the airplane departed BKW at 1137 and started a
climb. The airplane followed the interstate at various altitudes until 1300, when it started a descent from a GPS recorded altitude of about 3,350 feet. At 1308,
the airplane leveled off at a GPS altitude of 2,600 feet, and remained in straight and level flight until 1309 when the data ended in the vicinity of the accident
site.
A GoPro Hero rugged high definition video recorder was also recovered from the accident site; however, it contained no recorded data.
The pilot held a private pilot certificate with ratings for airplane single engine land and instrument airplane. According to the pilot, he did not possess a current
medical certificate and; therefore, was operating the airplane as a sport pilot. At the time of the accident he reported 4,399 total hours of flight experience;
1,423 hours of which were in the accident airplane make and model. The pilot's last instrument proficiency check was during 2005 .
The single-engine, fixed-gear, high wing, reciprocating engine powered airplane, was manufactured in 1939. It was powered by a Continental A75-A
75-horsepower engine, equipped with a Sensenich two-bladed propeller. According to the pilot the airplane was not certified for flight under instrument flight
rules.
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The National Weather Service (NWS) Boston Area Forecast indicated overcast clouds at 2,500 feet mean sea level (msl) with cloud tops at 7,000 feet, visibility
3-5 statute miles in mist. The weather was forecasted to improve between 1000 and 1300 with scattered clouds at 2,500 feet msl and broken clouds at 4,500
feet. The forecast also included an AIRMET Sierra for mountain obscuration with clouds and mist over the area.
The Washington, D.C. (ZDC) Air Route Traffic Control Center Meteorological Impact Statement (MIS) that was valid from 0729 to 1600 forecasted limited
instrument flight rule conditions due to low ceilings, reduced visibility and fog through 1100. The ZDC MIS also described marginal visual flight rule conditions
with patchy ceilings and mist across the Washington, D.C. area.
Weather, recorded at Twin County Airport (HLX), elevation 2,694 feet, at 1315, included winds from 180 degrees at 5 knots, visibility 10 statute miles, sky
overcast at 700 feet, temperature 19 degrees C, dew point 17 degrees C, an altimeter setting of 30.21 inches Hg. HLX was located 9 nm north of the accident
site.
According to a weather report obtained from the Virginia Department of Transportation, the weather recorded about a mile from the accident site, elevation
about 2,500 feet, at 1310 included wind calm, air temperature 18 degrees C, dew point 18 degrees C, and visibility 1,030 feet.
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03/19/2015 1715 CST Regis# N2722M
Acft Mk/Mdl PIPER PA 12-NO SERIES
Acft SN 12-1133
Midland, TX
Acft Dmg:
Fatal
Opr Name:
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Apt: Skywest Inc 7T7
0
Rpt Status: Prelim
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire:
All Rights Reserved
07/03/2014 1100 CDT Regis# N5923P
Monroeville, AL
Apt: Monroe County MVC
Acft Mk/Mdl PIPER PA 24-250
Acft SN 24-1010
Eng Mk/Mdl LYCOMING O-540 A1A5
Acft TT
Fatal
Opr Name: VANCE ALEXANDER
Opr dba:
5132
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Events
1. Approach-VFR go-around - Unknown or undetermined
Narrative
On July 3, 2014, about 1100 central daylight time, a Piper PA-24-250, N5923P, was substantially damaged during an aborted landing at Monroe County Airport
(MVC), Monroeville, Alabama. The flight instructor and a pilot rated passenger sustained minor injuries. Visual meteorological conditions prevailed, and an
instrument flight rules flight plan was filed for the personal flight, which was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.
The flight originated from Shelby County Airport (EET) Alabaster, Alabama at 1000.
According to a written statement by the flight instructor, he performed three landings at EET to obtain currency and subsequently departed for MVC with
another pilot onboard. After arriving at MVC, the instructor configured the airplane for an RNAV/GPS approach to runway 03. About 100 feet (ft) above ground
level (agl), the instructor initiated a go-around and retracted the landing gear and flaps. When the airplane reached about 400 ft agl the engine "sputtered, went
quiet, came back on briefly, and then went quiet again." The instructor then switched fuel tanks and verified that the fuel boost pump was on. He also observed
that the fuel mixture was set to rich and both magnetos were on. The instructor established best glide speed and selected a field to his right to conduct a forced
landing. During the landing, the airplane impacted a tree, the left wing separated, and the airplane came to rest inverted, resulting in substantial damage to both
wings and the fuselage.
A witness stated that the airplane engine started "sputtering" as it climbed away from the runway at an altitude of about 100 ft about 800 ft from the departure
end of runway 03. The airplane then entered a level flight attitude and the sputtering ceased. The witness heard the engine functioning, but not at full power.
The airplane climbed about 100 ft, began a right turn, and eventually started to descend until no longer in view.
During a follow-up interview, the instructor stated that the purpose of the flight was to familiarize the pilot-rated passenger with the operation of the
newly-installed global positioning system (GPS). Prior to the flight, the instructor visually inspected both wing tanks and estimated that each contained about 30
gallons of fuel. After starting the engine, the airplane sat at an idle power setting for about 30 minutes while the pilots configured the GPS prior to departure.
They then completed three takeoffs and landings at EET prior to departing for MVC. The airplane was flown for a total of 1 hour and 20 minutes with the fuel
selector on the left tank. The instructor also noted that he did not apply carburetor heat at any time following the loss of engine power.
Examination of the airplane and engine by a Federal Aviation Administration inspector (FAA) did not reveal any mechanical malfunctions which would have
resulted in a loss of engine power. The crankshaft was rotated by hand at the propeller, and continuity was established through the powertrain to the valvetrain
and the accessory section. Compression was confirmed on all cylinders, and the magnetos produced spark at all terminal leads. Fuel line continuity was tested
from the bladder tanks to the carburetor and was absent of contamination. The fuel strainer was void of debris and the carburetor screen contained minor
debris, but was not plugged. The carburetor had separated from the engine during the impact sequence; the floats were normal and there were no restrictions
inside the needle and seat. There were some rust and debris particles in the bottom of the carburetor fuel bowl, which likely accumulated during postaccident
storage of the wreckage. When the fuel boost pumps were connected to a 12 volt battery, both pumps produced suction at their respective inlets.
A weather observation taken at Middleton Field Airport (GZH), Evergreen, Alabama, located 16 nautical miles east of the accident site, about the time of the
accident reported wind from 350 degrees at 3 knots; visibility 10 statute miles; sky clear; temperature 27 degrees C, dewpoint 22 degrees C; altimeter 30.08
inches of mercury.
According to the manufacturer's pilot's operating handbook, at a cruise altitude of 6,000 feet, under standard atmospheric conditions, and at about 2,200 rpm,
the airplane's estimated fuel consumption was approximately 14 gallons per hour. Based on these values, the engine burned a total of about 22.4 gallons of fuel
during 1 hour and 36 minutes of flight time.
Review of an FAA carburetor icing envelope chart revealed a potential for serious icing at descent power given the atmospheric conditions present at the time
of the accident.
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02/27/2015 1159 EST Regis# N2122K
Jacksonville, FL
Apt: N/a
Acft Mk/Mdl PIPER PA 28-181
Acft SN 28-7990237
Rpt Status: Prelim
Eng Mk/Mdl LYCOMING O-360-A4M
Acft TT
Fatal
Opr Name: JACKSONVILLE NAVY FLYING CLUB
Opr dba:
10459
0
Ser Inj
0
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: STN
Events
Narrative
On February 27, 2015, about 1159 eastern standard time, a Piper PA-28-181, N2122K, collided with terrain near Jacksonville, Florida after a total loss of
engine power. The airplane was registered to and operated by Jacksonville Navy Flying Club under the provisions of Title 14 Code of Federal Regulations Part
91. The student pilot was not injured and the airplane sustained substantial damage. Visual meteorological conditions prevailed and no flight plan had been
filed. The instructional flight departed Lake City Gateway Airport (LCQ), Lake City, Florida, at 1130 and was destined for Jacksonville Naval Air Station,
Jacksonville, Florida.
The student pilot reported that the accident flight was a solo cross country flight. On the third and final leg of the flight, approximately 25 minutes after departure
from LCQ, the engine experienced a total loss of power. The student pilot elected to perform a forced landing to a nearby pasture. The airplane sustained
substantial damage to the fuselage and both wings during the forced landing. The airplane was recovered for further examination.
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01/11/2015 1246 MST Regis# N82828
Brighton, CO
Apt: Van Aire Airport CO12
Acft Mk/Mdl PIPER PA 28RT-201T
Acft SN 28R-8131015
Acft Dmg: DESTROYED
Acft TT
Fatal
Opr Name: TEFFT WADE H
Opr dba:
4106
1
Ser Inj
0
Aircraft Fire: NONE
Events
1. Maneuvering - Security/criminal event
Narrative
HISTORY OF FLIGHT
On January 11, 2015, at 1246 mountain standard time, a Piper PA-28RT-201T single-engine airplane, N82828, impacted terrain while maneuvering near
Brighton, Colorado. The airline transport pilot was fatally injured, and the airplane was destroyed. 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. Day visual meteorological conditions prevailed, and no flight plan
was filed. The flight departed from Van Aire Airport (CO12), Brighton, Colorado, about 1220.
According to witnesses who spoke with local authorities, the pilot taxied the airplane from inside his hangar and departed CO12. A witness described this as
unusual because the pilot would typically tug the airplane out of the hangar and then start the engine for a flight. For several minutes, witnesses observed the
airplane at a low altitude and maneuvering at high airspeeds. Witnesses last observed the airplane make a steep bank turn, descend, and impact terrain
approximately 5 miles east of the Van Aire Airport.
Local law enforcement, who spoke with the pilot's wife, had been advised that she believed he committed suicide. Recently, the pilot's wife had informed him
that she wanted a divorce and was purchasing a home nearby the pilot's residence. She stated that approximately five years ago, the pilot told her that if she
ever left him, he would fly his airplane into the ground and kill himself.
The pilot, age 41, held an airline transport pilot certificate, a commercial pilot certificate with an airplane single-engine land rating. In addition, the pilot held a
flight instructor certificate with airplane single-engine, multi-engine, and instrument ratings. The pilot's most recent Federal Aviation Administration (FAA)
first-class medical certificate was issued on November 20, 2014, with no limitations or restrictions.
According to the pilot's most recent airman medical certificate application, the pilot had accumulated 10,600 total flight hours and 200 flight hours in the
previous six months. The pilot's logbooks were not located during the investigation.
The four-seat, low-wing, retractable tricycle-gear airplane, serial number 28R-8131015, was manufactured in 1980. The airplane was powered by a Continental
Motors TSIO-360-FB1B, 200-horsepower engine, equipped with a Hartzell constant-speed propeller. The airplane was registered to the pilot on September 2,
2008.
A review of the airplane logbooks revealed the most recent annual inspection was completed on September 6, 2014. At that time, the airframe and engine had
accumulated 4,105.9 total hours. The engine had accumulated 88.3 hours since major overhaul.
At 1253, the Denver International Airport, Denver, Colorado, automated surface observing system, located approximately 11 miles southwest of the accident
site, reported the wind from 360 degrees at 9 knots, 10 miles visibility, few clouds at 5,000 feet, ceiling overcast at 11,000 feet, temperature 4 degrees Celsius,
dew point 1 degree Celsius, and an altimeter setting of 30.00 inches of Mercury.
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The airplane wreckage came to rest in a dormant wheat field, and airplane debris was distributed for approximately 200 feet along a bearing of 308 degrees.
The initial impact point, consistent with the left wing, was a continuous ground scar that extended 24 feet to a ground crater that measured 2.5 feet in depth.
The propeller assembly, engine, and a portion of the forward fuselage were located within the ground crater. The wings, fuselage cabin, and empennage were
fragmented and located within the debris field. All major components of the airplane were located at the accident site.
The cockpit and cockpit instrumentation were fragmented and destroyed. All four seats and seat assemblies were separated from their attach points. The left
wing and fuel tank were fragmented. The left aileron and flap remained partially attached to the wing structure. The right wing and fuel tank were fragmented.
The right aileron and flap remained partially attached to the wing structure. Both the left and right main landing gear assemblies were found in the retracted
position.
Partial control cable continuity was established due to fragmentation of the wreckage. The aileron cables remained attached to the chain assembly, and the
chain was separated in several sections. The fractured aileron cable ends were broomstrawed, consistent with an overload failure. Both the left and right aileron
bellcranks were separated and pulled from their attach points in the wings. The aileron cables were attached to their bellcranks and separated at the wing root.
The rudder cables were attached to their respective cockpit attach points. The cables were fractured and broomstrawed, consistent with an overload failure.
The rudder cable assembly was detached from the rudder pulley. The horizontal stabilator cables were separated from the lower T-bar, and the cables were
attached to the aft turnbuckle.
The engine sustained significant impact-related damage. The engine remained partially attached to the firewall. The spark plugs were impact damaged and
exhibited normal color and wear signatures. Due to damage, the crankshaft was partially rotated by a hand tool, and mechanical continuity was noted
throughout the engine. The engine crankshaft was fractured at the propeller flange; the fracture surface displayed 45 degree shear lips consistent with an
overload failure.
The propeller assembly remained attached to the fractured crankshaft propeller flange. One propeller blade was bent aft, tip curled, and contained chordwise
blade polishing. One propeller blade displayed s-type bending and contained chordwise blade polishing.
MEDICAL AND PATHEOLOGICAL INFORMATION
An autopsy was performed on the pilot by the Office of the Coroner for Adams and Broomfield Counties, Colorado. The listed cause of death was "multiple
blunt trauma injuries to the body due to airplane crash." The manner of death was determined to be suicide.
The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing on the pilot. The tests were negative for
all screened drugs and alcohol.
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05/26/2014 1930 EDT Regis# N4550M
Cooperstown, NY
Apt: Cooperstown-westville K23
Acft Mk/Mdl PIPER PA-11
Acft SN 11-1009
Eng Mk/Mdl CONT MOTOR C90 SERIES
Acft TT
Fatal
Opr Name: TOTH FRANK L
Opr dba:
2272
0
Ser Inj
0
Aircraft Fire: NONE
Events
1. Maneuvering - Loss of engine power (partial)
Narrative
On May 26, 2014, about 1930 eastern daylight time, a Piper PA-11, N4550M, was substantially damaged when it impacted a pole barn near Cooperstown, New
York. The private pilot and the passenger were not injured. Visual meteorological conditions prevailed, and no flight plan had been filed for the local flight that
departed Cooperstown-Westville Airport (K23), Cooperstown, New York. The personal flight was conducted under the provisions of 14 Code of Federal
In a statement to New York State Police, the pilot reported that after takeoff, he completed a "few" takeoffs and landings, then took a scenic flight in the vicinity
of the airport. As he was preparing to land, just north of the airport about 750 feet above the ground, the pilot noticed a "considerable" loss of engine power. As
in the past, he applied carburetor heat, but it was not enough to be able to climb the airplane, which was rapidly losing altitude. The pilot decided to land on the
road next to the airport, but with no power, the airplane dropped over some trees and impacted a pole barn.
In a follow-up statement, the pilot noted that he was set up on a long final approach to runway 20 at K23 when the passenger asked to see a lake. The pilot
climbed the airplane out to the west, then the passenger requested to see another lake to the south. The pilot changed course, and after doing so, the engine
developed carburetor ice. The pilot could not clear the ice and the engine lost power. At the time, the airplane was near a ridge west of the airport at a low
altitude, and the pilot felt he couldn't turn back to the airport safely, so he tried an emergency landing next to, and to the west of route 166. During the landing,
the airplane's left wing impacted the power pole and spun the airplane around, which then slid backwards [into the hangar.]
According to the responding Federal Aviation Administration (FAA) inspector, the airplane came to rest 450 feet west of K23 runway 2/20 centerline, off airport
property abeam the north end of tee hangars that paralleled the runway, and across route 166, which also paralleled the runway. The airplane came to rest
heading about 125 degrees magnetic.
The left wing leading edge was impact damaged, consistent with hitting a utility pole located on the west side of the road that paralleled the runway. About 4
feet above the ground, the pole exhibited damage and paint transfer the same color as the airplane. Left wing damage started just outboard the fuel tank to the
tip.
From photographs, there were ground scars from the utility pole to where the airplane came to rest. The airplane came to rest up against the pole barn with the
left wing down to the ground, and the right wing up against the barn. The right wing was partially penetrating a corner of the pole barn, with the leading edge
outside of the barn wall, and the trailing penetrating the barn wall.
The FAA inspector also noted that the left main landing gear was bent under and aft with the left main wheel and tire assembly broken off the left axel. The
carburetor and air box were broken away from the engine and the carburetor heat and throttle cables were separated. One propeller blade was bent forward
slightly, while the opposite blade was bent aft; and both had leading edge tip damage. In addition, there were four ground score marks located between the
utility pole and airplane consistent in appearance with propeller strikes.
The pilot also reported that, at 1800, the temperature was 24 degrees C and the dew point was 11 degrees C. At 1953, the nearest airport with recorded
weather, about 40 nautical miles to the northwest, recorded the same temperature and dew point. An FAA carburetor icing probability chart indicated the
probability of "serious icing at glide power," and the pilot wrote that he "should have turned on the carb heat.earlier on final."
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03/21/2013 840 EDT
Regis# N625SR
Perry, FL
Acft Mk/Mdl PIPER PA-23-250
Acft SN 27-7654067
Eng Mk/Mdl LYCOMING IO 540 C4B5
Acft TT
Fatal
Opr Name: CONSOLIDATED CITRUS
Opr dba:
5219
0
Apt: Perry-foley 40J
Ser Inj
0
Aircraft Fire: NONE
Events
1. Enroute-descent - Loss of engine power (total)
Narrative
On March 21, 2013, about 0840 eastern daylight time, a Piper PA-23-250, N625SR, was substantially damaged during a forced landing into trees 4 miles
southwest of Perry, Florida. The airline transport pilot received minor injuries and was the sole occupant. Visual meteorological conditions prevailed and an
instrument flight rules flight plan was filed. The flight originated at the Orlando Executive Airport (ORL), Orlando, Florida, about 0735 with an intended
destination of Tallahassee Regional Airport (TLH), Tallahassee, Florida. The executive/corporate flight was conducted under the provisions of Title 14 Code of
Federal Regulations Part 91.
According to the pilot, while in cruise flight the left fuel flow was "fluctuating," he activated the electric fuel pump, and the fuel flow stabilized. After a few
minutes of a stabilized fuel flow, he deactivated the electric fuel pump, and the fuel flow remained "stable." He initiated a descent from a cruise altitude of 8,000
feet above mean sea level and switched to the "full" outboard fuel tanks. He then noted that his right engine began to lose power and subsequently experienced
a total loss of power. He feathered the right propeller and selected the right mixture to idle cut off. The pilot informed Tallahassee Approach Control of the
engine failure and elected to continue his flight as planned to TLH. As he was making this determination the left engine experienced a total loss of power. The
pilot maneuvered the airplane toward Perry-Foley Airport (40J), Perry, Florida and declared an emergency. The airplane subsequently impacted 16-foot tall pine
trees prior to coming to rest upright.
Local authorities reported that upon arrival there was a strong fuel "aroma" at the accident location.
A fuel receipt from a fixed base operator (FBO) revealed that two days prior to the accident the airplane was fueled with 94.1 gallons of fuel, according to the
pilot the "aircraft fuel was full." A sampling of the fuel was conducted following the accident and no contamination was noted. The FBO further reported that
about 1000 gallons of fuel had been pumped from the time the accident airplane was fueled until they were notified of the accident.
Photographs provided by a Federal Aviation Administration (FAA) inspector revealed substantial damage to both wings, fuselage, and empennage. The FAA
inspector further reported that the left wing tip fuel tank was separated from the airplane, engine continuity was confirmed; however, cylinder compression
checks were unable to be accomplished. Fuel lines were removed from the electric fuel boost pumps and both engine driven fuel pumps and fuel was present
in all of the fuel lines examined. The fuel lines were removed from the engine flow dividers and the left engine flow divider contained fuel and the right engine
flow divider was devoid of fuel. Continuity was verified from the left and right throttle control and mixture control to the fuel servos. Continuity was verified from
the left and right fuel selectors to the fuel shut-off valves; however, the tank selected at impact was not noted. All magneto switches were found in the "ON"
position. The pilot reported to the FAA, that he had switched the fuel selector valve from the inboard fuel tanks to the outboard fuel tanks just prior to the engine
failure. The pilot also reported that the fuel tanks were switched starting with the right engine and then the left engine.
The fuel system contained two independent units that allow each engine to have its own fuel supply. The fuel cells consist of two bladder type fuel tanks
located in each wing designated as an "inboard" and "outboard" fuel tank and a wingtip fuel tank that was interconnected to the associated outboard fuel cell.
The outboard fuel cell, including the wingtip tank had a capacity of about 55 gallons of fuel each, and the inboard fuel cells had a capacity of 35 gallons of fuel
each; total fuel capacity was about 180 gallons for the airplane. The system was designed to take fuel from each fuel cell through a finger screen then to the
fuel selector valve. After the selector valve, fuel was routed either directly to the engine driven fuel pump or through the electric fuel pump. The systems were
connected only by a crossfeed valve that allowed fuel to be drawn from one set of fuel cells to the engine on the opposite side, after passing through the engine
driven fuel pump. The fuel selector valves consisted of control handles located on the fuel control box between the two front seats.
According to a representative of the salvage company that recovered the airplane, the fuel tanks were breached and devoid of fuel; there was a strong fuel
smell at the accident location. However, the airplane wreckage was sold and was not available to be examined by the NTSB, and thus no determination could
be made as to why both engines lost power.
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01/15/2015 1600 EST Regis# N354TW
Punta Gorda, FL
Apt: Punta Gorda PGD
Acft SN 27-2882
Rpt Status: Prelim
Acft TT
Fatal
Opr Name: JOSEPH PIANA
Opr dba:
4543
0
Ser Inj
0
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: STN
Events
Narrative
On January 15, 2015, at 1600 eastern standard time, N354TW, a twin-engine Piper PA-23-250, sustained substantial damage during landing at the Punta
Gorda Airport (PGD), Punta Gorda, Florida. The airline transport rated pilot and his two passengers were not injured. The airplane was registered to and
operated by a private individual. Visual meteorological conditions prevailed and no flight plan was filed for the local flight conducted under the provisions of 14
Code of Federal Regulations Part 91.
The pilot stated that he had conducted several touch and go's and everything was normal until the last landing. He said he felt a vibration, like a flat tire, on the
right side. The pilot said the airplane continued to descend after landing and that is when he realized the landing gear had collapsed. Once the airplane came to
a stop, he and the passengers exited the airplane. The pilot said that the landing gear handle was in the down and locked position and the front seat passenger
did not accidentally move the gear handle during the flight. A postaccident examination of the airplane and landing gear was conducted by a mechanic based at
the airport. Substantial damage was noted to the lower fuselage. Additionally, the airplane was lifted and the landing gear was swung several times. No
mechanical deficiencies were identified that would have caused the gear to collapse on landing.
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03/09/2015 1200 AST Regis# N1153P
Acft SN 23-166
Opr Name: PESQUERA RAFAEL A
San Juan, PR
Apt: Fernando Luis Ribas Dominicci TJIG
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
0
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: STN
Events
Narrative
On March 9, 2015, about 1200 Atlantic standard time, a Piper PA-23-250, N1153P, was substantially damaged when it impacted a lagoon after the right engine
experienced a total loss of power during initial climb near San Juan, Puerto Rico. Visual meteorological conditions prevailed and a visual flight rules flight plan
was filed for the personal flight. The commercial pilot and one passenger were not injured. The flight was conducted under the provisions of Title 14 Code of
Federal Regulations Part 91. The flight departed Fernando Luis Ribas Dominicci Airport (SIG), San Juan, Puerto Rico, around 1200, with the intended
destination of Cyril E. King Airport, St. Thomas, United States Virgin Islands (STT).
According to the pilot, he had the airplane fueled so that there was a total of 50 gallons of 100LL aviation fuel in the airplane, 25 gallons of fuel in each wing. He
then performed an engine run up and all parameters were "normal." The airplane departed runway 09, the pilot obtained a positive rate of climb of 500 feet per
minute, and an indicated airspeed of 105 mph. About 300 feet above ground level, the right engine experienced a total loss of power. The pilot identified the
loss of power in the right engine and feathered the propeller. Subsequently, he noticed that the airplane was unable to maintain altitude and looked for a place
to land the airplane. He identified that the safest place to land the airplane was the lagoon off to the right and maneuvered the airplane to perform an
emergency landing in the water. During the final approach to the water, the pilot put the mixture for the right engine in the "off" position and shut down the left
engine. After impacting the water, the pilot and passenger egressed the airplane without injury.
According to witnesses, they heard the airplane "sputter, pop," and then the engine went quiet. They then looked up, saw grey smoke coming from the right
engine, and noticed that the airplane banked toward the lagoon. The airplane continued toward the lagoon and they lost sight of it as it flew behind a building.
The engines were retained for examination.
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03/09/2015 1410 EDT Regis# N6514P
Acft SN 24-1636
Opr Name: GREGORY PIEHL
Fort Myers, FL
Apt: Page Field FMY
Rpt Status: Prelim
Fatal
1
Ser Inj
Opr dba:
1
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: STN
Events
1. Approach-VFR pattern final - Loss of engine power (total)
Narrative
On March 9, 2015, about 1410 eastern daylight time, a Piper PA-24-250, N6514P, was substantially damaged during collision with a vehicle and storage
container after a total loss of engine power on final approach to Page Field Airport (FMY), Fort Meyers, Florida. The private pilot was seriously injured and the
passenger was fatally injured. Visual meteorological conditions prevailed, and no flight plan was filed for the personal flight, which was conducted under the
provisions of Title 14 Code of Federal Regulations Part 91. The flight departed St. Pete-Clearwater International Airport (PIE) about 1335 and was destined for
FMY.
In a telephone interview, the pilot stated the airplane's fuel tanks contained about 85 gallons of fuel prior to departure. He said that preflight inspection, engine
start, engine run-up, taxi and takeoff were as expected and that "all systems were normal." The pilot took off and climbed the airplane to 3,500 feet. About 10
miles from FMY, the pilot contacted air traffic control (ATC), and he was instructed to report again at 4 miles from the airport. The pilot moved the fuel selectors
from the auxiliary to main tank positions. At 4 miles from FMY, the pilot contacted ATC and configured the airplane for landing.
On final approach for landing, at an altitude about 500 feet, the engine stopped producing power. The propeller continued to rotate, but the engine did not
respond to throttle inputs. The pilot switched the fuel selectors back to the auxiliary tank position and turned on the electric fuel boost pumps, but never
regained engine power. The pilot said that each time he moved the fuel selectors, he visually confirmed their position. The pilot performed a forced landing to a
parking lot which resulted in substantial damage to the engine compartment and fuselage.
Examination of the airplane by a Federal Aviation Administration inspector revealed no odor of fuel, or evidence of fuel spillage at the scene; however, removal
of the fuel caps revealed large quantities of fuel in each wing. The engine controls were all "full forward" and both fuel selectors were in the "Off:" position. The
wreckage was moved from the accident site for a detailed examination at a later date.
The pilot held a private pilot certificate with a rating for airplane single-engine land. He reported 450 total hours of flight experience, of which "more than" 10
hours were in the accident airplane make and model. His most recent FAA third class medical certificate was issued on February 24, 2015.
The airplane was manufactured in 1959 and was equipped with a Lycoming O-540 series, 250 hp, reciprocating engine. The airplane's maintenance history
could not be immediately determined.
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03/04/2014 1650 EST Regis# N1449H
Atlantic City, NJ
Apt: Atlantic City Intl ACY
Acft SN 28-7716025
Eng Mk/Mdl LYCOMING O-320
Acft TT
Fatal
Opr Name: FAA FLYING CLUB INC
Opr dba:
5038
0
Ser Inj
0
Aircraft Fire: NONE
Events
Narrative
On March 4, 2014, at 1650 eastern standard time, a Piper PA-28-161, N1449H, operated by the FAA Flying Club, INC, was substantially damaged when it
collided with terrain and a fence during a forced landing following a partial loss of engine power after takeoff from Atlantic City International Airport (ACY),
Atlantic City, New Jersey. The airline transport pilot received minor injuries. Visual meteorological conditions (VMC) prevailed, and no flight plan was filed for
the personal flight, which was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.
In a written statement, the pilot stated the purpose of the flight was to travel in order to give a presentation on cold weather survival and civilian air intercept
procedures. He said he specifically checked to see if the airplane was "clear of snow and ice" prior to departure, and determined that it was, but then later
described clearing the "minor snow accumulation" at the bottom of the engine compartment. The pilot described his preflight inspection, engine start, taxi,
run-up, and before takeoff checks as performed in accordance with the checklist.
He then described a "normal" acceleration of the engine during the takeoff roll, with a "slight hesitation" at 2,200-2,300 rpm, as he continued the takeoff. At 70
knots and over the departure end of the runway, the engine "lost significant power." Rather than attempt a return to the runway, or land straight ahead to
wooded terrain, the pilot elected to perform a forced landing to the airport perimeter road. Just prior to ground contact, the airplane's left wing struck a tree and
a fence, and the airplane impacted the road and came to rest inverted.
The pilot held a commercial pilot certificate with ratings for airplane single engine land and instrument airplane. He also held an airline transport pilot certificate
with a rating for rotorcraft-helicopter. His most recent Federal Aviation Administration (FAA) third class medical certificate was issued on October 21, 2013. He
reported 3,245 total hours of flight experience, of which 318 hours were in single-engine airplanes.
According to FAA records, the airplane was manufactured in 1977. Its most recent annual inspection was completed September 12, 2013, at 5,038.1 aircraft
hours. The airplane accrued 37.1 hours of flight time after the inspection.
At 1654, the weather conditions reported at ACY included calm winds, clear skies, and 10 miles of visibility. The temperature was -4 degrees C, the dew point
was -9 degrees C, and the altimeter setting was 30.28 inches of mercury.
Examination of photographs revealed the airplane came to rest inverted on the airport perimeter road, entangled in a fence. The left wing was separated from
the airplane at the wing root. Photographs taken at the original point of touchdown, revealed slash and paint transfer marks in the pavement that were
consistent with the color and dimension of the propeller blades. The airplane was removed from the site, and recovered to the operator's ramp space at ACY.
Later, it was moved to an aircraft recovery facility in Clayton, Delaware for a detailed inspection which was performed by the FAA on May 14, 2014.
The airplane was secured to a flatbed trailer, with the left wing separated by impact, and the right wing removed by recovery personnel. A substitute propeller
and aircraft battery were installed, and an auxiliary fuel supply was plumbed into the fuel system to attempt an engine run.
The engine started immediately, accelerated smoothly, and ran without interruption. The magnetos were tested, and found to be functioning as designed.
Several rpm changes, through rapid accelerations and decelerations, were accomplished with smooth operation throughout.
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12/26/2013 530 EST
Regis# N8372Y
Biglerville, PA
Acft SN 30-1526
Acft Dmg: DESTROYED
Fatal
Eng Mk/Mdl LYCOMING IO-320 SERIES
Opr Name: BRONZBURG MICHAEL C
2
Apt: N/a
Ser Inj
Opr dba:
0
Aircraft Fire: NONE
Events
1. Enroute - Loss of control in flight
Narrative
HISTORY OF FLIGHT
On December 26, 2013, about 0530 eastern standard time, a Piper PA-30, N8372Y, was destroyed following an inflight break up, and impact with terrain near
Biglerville, Pennsylvania. Night visual meteorological conditions prevailed and no flight plan was filed for the flight. The certificated private pilot and passenger
were fatally injured. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. The flight originated from
Bloomsburg Municipal Airport (N13), Bloomsburg, Pennsylvania, around 0445, with an intended destination of Summerville Airport (DYB), Summerville, South
Carolina.
According to witnesses, the airplane was flying "low" and the engine noise was "loud." One witness reported that he heard the engine "miss" once, then the
engine "revved up," and a few seconds later he heard the sound of impact. Another witness stated that when he heard the engine "spike."Radar tracking data
that was obtained from the Federal Aviation Administration (FAA) Harrisburg Approach Control Radar facility located in Harrisburg, Pennsylvania. The radar
data indicated that, the airplane was flying on a southwesterly heading at an altitude around 10,000 feet mean sea level (msl). Then around 0525, the airplane
descended to 7,400 feet msl. At 0527 the airplane entered a left turn and descended. A few seconds later the radar target completed a 180 degree turn and the
data indicated a 2,000 foot per minute descent and a 7.5 degrees per second turn rate. The last radar data, located in/near the accident location indicated that
the airplanewas at 2,700 feet msl and a recorded ground speed of 179 knots.
According to FAA records, the pilot held a private pilot certificate with ratings for airplane single-engine land and multiengine land, and a third-class medical
certificate issued on October 31, 2013, which included a restriction of "must wear corrective lenses for near and distant vision."
The pilot's logbook was recovered from the accident site and it listed a total of 196.1 hours of flight time. It also indicated that the pilot recorded a total of 12.3
hours of flight time at night, 1.2 hours of flight in actual instrument conditions, and 3.8 hours of flight time in simulated instrument conditions. In addition, there
were 4.5 hours of flight time is the past 12 months, of which 4 hours occurred between December 20, 2013, and December 25, 2013.
According to FAA records, the airplane was issued an airworthiness certificate in 1967 and was registered to the pilot on June 18, 2012. It was equipped with
two Lycoming IO-320-series, 160- horsepower engines. It was also equipped with two 2-bladed Hartzell controllable pitch propellers. At the time of this writing,
the maintenance logbooks had not been located. However, a receipt for maintenance performed on the airplane included an annual inspection that was dated
November 18, 2014.
An observation site from a National Weather Service source for Fountain Dale (RYT), Hamiltonban, Pennsylvania, located approximately 15 miles southwest of
the accident site, at the time of the accident, showed rapidly changing conditions during the period with a band of snow moving across the region.
The RYT weather observation at 0453 indicated wind from 220 degrees at 3 knots, visibility 10 miles, ceiling overcast clouds at 7,000 feet above ground level
(agl), temperature minus 4 degrees C, dew point minus 8 degrees C, and an altimeter setting 30.22 inches of mercury.
The RYT weather observation at 0553 indicated wind calm, visibility 10 miles, ceiling overcast at 3,200 feet agl, temperature minus4 degrees C, dew point
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minus 9 degrees C, and an altimeter setting of 30.21 inches of mercury.
The RYT weather observation at 0608 indicated calm wind, visibility 3 miles in light snow, ceiling broken at 2,800 feet, overcast at 7,000 feet, temperature
minus 4 degrees C, dew point minus 8 degrees C, and an altimeter setting of 30.20 inches of mercury. In addition, the remarks section stated that snow began
at 0556.
According to the Astronomical Applications Department at the United States Naval Observatory, the official moonset was at 1224, the official beginning of civil
twilight was at 0659, and official sunrise was at 0729. The phase of the moon on the day of the accident was waning crescent, with 38 percent of the moon's
visible disk illuminated.
A search of Flight Service Station records revealed that the pilot requested weather information and Notice to Airman (NOTAMs) on the day of the accident for
Williamsport Regional Airport (IPT), Williamsport, Pennsylvania, and Farmville Regional Airport (FVX), Farmville, Virginia. The pilot did not file a flight plan and
did not receive any other services for the accident flight.
The weather reported at IPT, which was approximately 27 miles northwest of the departure airport, around the departure time, indicated wind from 090 at 8
knots, visibility 1 _ statute mile, light snow, clouds overcast at 2,600 feet agl, temperature minus 4 degrees C, dewpoint minus 7 degrees C.
The airplane impacted the ground and came to rest inverted. The wreckage path was oriented on a 179 degree heading and the debris path began about 2,350
feet prior to where the main wreckage came to rest. The main wreckage was oriented on about a 180 degree heading. Several pieces of airframe skin were
located in the field leading up to the main wreckage. The first piece of airframe skin was located approximately 2,350 feet prior to the main wreckage. First
responders reported an odor similar to 100LL in the field where the main wreckage was located.
The nose landing gear was located in the vicinity of and was separated from, the main wreckage.
The left and right engines were separated from the main wreckage, embedded in the field, and located approximately 10 feet from the main wreckage. When
they were removed from the ground, fuel and oil were present in the craters.
One propeller blade was located in the field approximately 400 feet from the main wreckage and its associated propeller hub was located in the field
approximately 500 feet from the main wreckage . The other propeller blade was not located. The second propeller was located about 50 feet aft of the main
wreckage. Both blades remained attached to the propeller hub and flange. Both spinners were separated from the engines and located in the field along the
debris path.
The outboard 6 foot of the right wing was located along the debris path about 600 feet from the main wreckage in the field. The inboard approximate 10 feet
remained attached to the fuselage and exhibited crush damage. The right wing tip, was separated and located approximately 50 feet from the outboard section
of the right wing. The right aileron remained attached to the right outboard section of the wing through one attach point. The right flap remained attached to the
right wing through all attach points. The right wing fuel cap remained intact and seated, however that section was separated from the right wing. The right main
landing gear remained attached to the right wing in the retracted position.
The aft section of the fuselage was separated at the aft pressure bulkhead. The rudder, vertical stabilizer, and inboard section of the left stabilator was located
about 200 feet from the main wreckage. The right section of the stabilator was located approximately 675 feet from the main wreckage in an area of trees. The
forward section of the left stabilator remained attached to the empennage. The main spar of the stabilator remained attached to the aft bulkhead. The rudder
remained attached to the vertical stabilizer through all attach points and exhibited impact damage.
The outboard approximate 6 foot of the left wing was found separated from the fuselage and located in a field about 600 feet from the main wreckage. The left
aileron was located in the field approximately 200 feet from the left outboard section of the wing. The inboard approximate 10 feet of the left wing remained
attached to the fuselage and exhibited crush and impact damage. The forward section of the left wing was separated from the left wing spar and located
approximately 10 feet forward of the main spar. The left inboard section of the flap remained attached to the inboard section of the wing through the outboard
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attach point. Aileron control cable continuity was confirmed from the base of the control column to the associated fracture points out to the aileron attach point.
The aileron cable exhibited tensile overload at all fracture points. The main landing gear remained in the up and in the retracted position.
The cockpit exhibited extensive crush damage and was separated from the fuselage. The engine controls were intact. The throttle levers and propeller levers
were in the midrange position. Flight control continuity was confirmed from the cockpit to all flight control surfaces through the respective tensile overload
breaks. The air driven attitude indicator was disassembled and the gyro and gyro housing exhibited rotational scoring, consistent with operating at the time of
impact. The electric turn and bank indicator was disassembled and the internal gyro and housing exhibited rotational scoring, consistent with operating at the
time of impact.
The fuselage came to rest inverted in a corn field and it exhibited extensive impact damage The inboard section of the main wing spar remained attached to the
fuselage. All seats were separated from the fuselage. The fuel selector valves were located in the fuselage and were disassembled. Both fuel selectors
contained a fluid that tested positive for water using the water detecting paste.
An autopsy was performed on the pilot on December 27, 2013, by Forensic Pathology Associates, Allentown, Pennsylvania. The autopsy findings included the
cause of death as "multiple injuries."
toxicology report stated no ethanol or drugs were detected in the liver.
TESTS AND RESEARCH
Engine Examinations
Both engines were examined at Anglin Aircraft Recovery in Clayton, Delaware. They were removed from storage and placed on pallets prior to the investigation
team arrival. Upon arrival, the team determined which engine was the left and the right. The examination revealed that there were no mechanical malfunctions
or abnormalities that would have precluded normal operation with either engine.
A detailed engine examination report for each engine are available in the official docket of this investigation.
Electronic Devices
A Garmin GPSMAP 696, an iPhone, a Motorola Droid X, and an iPad were found in the main wreckage area, retained, and sent to the National Transportation
Safety Board Recorders laboratory for data download. Data was unable to be extracted from the iPhone nor the Motorola Droid X due to impact damage.
The Garmin GPSMAP 696 contained data that was recorded at the time of the accident flight. The data began at 0439 and continued until 0528. The last
recorded data points indicated that the airplane was on a direct course to DYB, made a slight right turn approximately 45 degrees away from the track toward
DYB at 0524. Then, it made a turn back to the left approximately 90 degrees, to the right approximately 90 degrees, and finally, it banked to the left and
continued the bank and began a descent until the data points ended. The last data point recorded a ground speed of 141 knots.
Spatial Disorientation
According to the FAA Airplane Flying Handbook (FAA-H-8083-3), "Night flying is very different from day flying and demands more attention of the pilot. The
most noticeable difference is the limited availability of outside visual references. Therefore, flight instruments should be used to a greater degree.. Generally, at
night it is difficult to see clouds and restrictions to visibility, particularly on dark nights or under overcast. The pilot flying under VFR must exercise caution to
avoid flying into clouds or a layer of fog." The handbook described some hazards associated with flying in airplanes under VFR when visual references, such as
the ground or horizon, are obscured. "The vestibular sense (motion sensing by the inner ear) in particular tends to confuse the pilot. Because of inertia, the
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sensory areas of the inner ear cannot detect slight changes in the attitude of the airplane, nor can they accurately sense attitude changes that occur at a
uniform rate over a period of time. On the other hand, false sensations are often generated; leading the pilot to believe the attitude of the airplane has changed
when in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation."
According to the FAA Instrument Flying Handbook (FAA-H-8083-15), a rapid acceleration "...stimulates the otolith organs in the same way as tilting the head
backwards. This action creates the somatogravic illusion of being in a nose-up attitude, especially in situations without good visual references. The disoriented
pilot may push the aircraft into a nose-low
or dive attitude."
The FAA publication Medical Facts for Pilots (AM-400-03/1), described several vestibular illusions associated with the operation of aircraft in low visibility
conditions. Somatogyral illusions, those involving the semicircular canals of the vestibular system, were generally placed into one of four categories, one of
which was the "graveyard spiral." According to the text, the graveyard spiral, ".is associated with a return to level flight following an intentional or unintentional
prolonged bank turn. For example, a pilot who enters a banking turn to the left will initially have a sensation of a turn in the same direction. If the left turn
continues (~20 seconds or more), the pilot will experience the sensation that the airplane is no longer turning to the left. At this point, if the pilot attempts to
level the wings this action will produce a sensation that the airplane is turning and banking in the opposite direction (to the right). If the pilot believes the illusion
of a right turn (which can be very compelling), he/she will reenter the original left turn in an attempt to counteract the sensation of a right turn. Unfortunately,
while this is happening, the airplane is still turning to the left and losing latitude.
Pulling the control yoke/stick and applying power while turning would not be a good idea-because it would only make the left turn tighter. If the pilot fails to
recognize the illusion and does not level the wings, the airplane will continue turning left and losing altitude until it impacts the ground."
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01/01/2013 2240 CST Regis# N7700Y
Jasper, AL
Apt: Walker County Airport JFX
Acft SN 30-785
Acft Dmg: DESTROYED
Acft TT
Fatal
Opr Name: ALBERT D. WHITWORTH
Opr dba:
1370
3
Ser Inj
0
Aircraft Fire: NONE
Events
2. Uncontrolled descent - Miscellaneous/other
Narrative
HISTORY OF FLIGHT
On January 1, 2013, about 2240 central standard time, a twin-engine Piper PA-30, N7700Y, collided with terrain during an uncontrolled descent in Jasper,
Alabama. The student pilot and two passengers were fatally injured, and the airplane was destroyed. The airplane was unregistered and was owned by a
private individual. The unauthorized flight was conducted in night, instrument meteorological conditions and no flight plan was filed. The flight departed from
Walker County Airport-Bevill Field, Jasper, Alabama, at 2235.
Witnesses stated that, on the night of the accident, it was dark and raining. They heard an airplane flying very low and, shortly thereafter, they heard a loud
crash. The witnesses called the local authorities and reported that the airplane had crashed.
According to the airport manager/instructor, the student pilot worked as a cleanup person at the airport in trade for flight lessons. The airport manager said that
the student pilot completed 10 hours of dual instruction and a solo flight on April 27, 2012. He also said that the student pilot received his flight lessons in a
Cessna C-172 airplane. The student pilot completed two other supervised solos before enrolling at the Wallace State Community College aviation program. He
continued coming to the airport and doing odd jobs for various airplane owners in exchange for rides. The airport manager and had no knowledge of the student
ever taking any other lessons.
The owner of the airplane stated that he knew the student pilot from seeing him around the airport. He went on to say that he never gave permission to the
student pilot to fly his airplane. He said that the student pilot did not have a key for his airplane, and it was not kept locked. On the night of the accident, the
owner was informed that his airplane was missing from the airport. When he arrived at the airport, he verified that his airplane was missing and reported that it
was last seen on December 23, 2012.
According to the Federal Aviation Administration (FAA), the student pilot made no contact with air traffic control facilities prior to the accident, and there were
no known radio transmissions.
The pilot, age 17, held a student pilot certificate and reported a total of 6 hours of flight time in the last 6 months as of the exam dated February 28, 2012. The
student pilot was issued a class 3 medical certificate with limitations for corrective lenses. Review of FAA records did not reveal any other certifications other
than the student pilot certificate. A review of copies of the student pilot's logbook revealed that he had accumulated total of 15.5 flight hours as of September
16, 2012. The logbook showed that, on April 27, 2012, he was signed off on his first solo flight. On August 26, 2012, he was signed off for the private pilot
knowledge test, but there are no records of him taking the test. The student pilot's logbook did not show any entries or endorsements related to multi-engine,
night, or instrument flights.
The four-seat, low-wing airplane, serial number 30-785, was manufactured in 1965. It was powered by two Lycoming model IO-320-B1A 160-hp engines
equipped with Hartzell HC-E2YL-2BS hubs and F7663-4 blades. Review of copies of maintenance logbook records showed an annual inspection was
completed August 13, 2012, at a recorded airframe total time of 1369.5 hours and a total time of 5160.6 hours.
The recorded weather at the Walker County-Bevill Field, Jasper, Alabama (JFX) at an elevation of 483 feet, revealed at 2255, conditions were wind 350
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degrees at 8 knots, cloud conditions broken at 400 feet above ground level, temperature 45 degrees Celsius (C); dew point 43 degrees C; altimeter 30.11
inches of mercury. A witness reported that there was fog and mist in the area at the time of the accident.
The airplane was found in heavily wooded area about 1 mile southwest from JFX. The fuselage of the airplane came to rest on a course of 050 degrees
magnetic. The cockpit and cabin were crushed and fragmented. The nose gear assembly was broken away from the fuselage and located along the debris
path. The instrument panel and instruments were impact damaged. The empennage remained attached to the fuselage and was buckled. The vertical and
horizontal stabilizers were still attached and buckled. The rudder and elevators remained attached to the flight surfaces at the attachment points, and the
respective flight control cables were connected. The left and right aileron cables were broken in overstress, and the ends of the cables remained attached to
their respective bellcranks. Flight control continuity was established from the flight controls to the flight control surfaces. The left and right fuel selectors were
found in the on position.
The right wing was attached to the fuselage at the wing root, and the outboard section was fragmented throughout the debris path. The right engine was broken
away from the wing nacelle and was impact damaged. The right main fuel tanks were breached, and the fuel caps were secured to the wing. The main landing
gear assembly was broken away from the wing and was located on the debris path in the extended position.
The left wing was attached to the fuselage at the wing root, and the outboard section extending past the engine nacelle was fragmented throughout the debris
path. The engine remained attached to the wing nacelle and was impact damaged. The left main fuel tanks were breached, and the fuel caps were secure. The
left main landing gear was found in the extended position.
Examination of both engines revealed that the propellers remained attached to the hubs. Both propeller blade assemblies displayed "S" bending and scoring
throughout the blade spans. There was evidence of propeller blade cuts on tree branches throughout the accident site. The branches measured approximately
4-inches in diameter and were found within the debris path severed cleanly in diagonal linear patterns. There were no discrepancies noted that would have
precluded normal operation of both propeller blade assemblies. Both engines remained attached to their respective wings, and each showed crush damage.
Examination of both engines did not reveal any anomalies that would have precluded normal operation.
An autopsy was performed on the student pilot on January 3, 2013, by the Alabama Department of Forensic Sciences, Huntsville, Alabama. The autopsy
findings included blunt force injuries, and the report listed the specific injuries. The cause of death was reported as three of the listed injuries.
toxicology report stated no ethanol was detected in the liver or the muscle, and no drugs were detected in the liver.
A review of video footage retrieved from the airport security camera showed that, on the night of the accident, an airplane is seen taxiing on the ramp at a high
rate of speed to the active runway. As the airplane departs the strobes lights are seen reflecting off of the runway and continue up into a low cloud ceiling. The
strobes are then seen pulsating in the clouds before being lost from the camera's view.
Title 14 Code of Federal Regulations (CFR) Part 61.89(a) states, in part, that a student pilot may not act as pilot in command of an aircraft that is carrying a
passenger, or when the flight cannot be made with visual reference to the surface, or in any manner contrary to any limitations placed in the pilot's logbook by
an authorized instructor.
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08/23/2012 1630 PDT Regis# N222BP
Acft Mk/Mdl PIPER PA-30 B
Acft SN 30-1510
Acft TT
Fatal
Opr Name: PEARSON, WARD N
Opr dba:
5657
Scappoose, OR
0
Ser Inj
Apt: Scappoose Industrial Airpark SPB
0
Aircraft Fire: NONE
AW Cert: STN
Summary
The pilot reported that the landing gear would not fully extend before landing. He attempted to extend the gear manually but was unsuccessful. The pilot
decided to make a gear-up landing on the grass median next to the runway. During the landing, the airplane sustained substantial damage to the lower
fuselage. A postaccident examination of the airplane revealed that there was a failure of the landing gear transmission assembly, which prevented the full
extension of the nose landing gear. After the accident, the transmission was replaced, and the failed transmission was not retained for further testing, which
precluded a determination of the reason for the failure of the landing gear to fully extend.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The failure of the landing gear to
fully extend as a result of a failure of the landing gear transmission assembly for reasons that could not be determined based on the available evidence.
Events
1. Landing - Sys/Comp malf/fail (non-power)
2. Landing-flare/touchdown - Off-field or emergency landing
2. Environmental issues-Physical environment-Runway/land/takeoff/taxi surface-Soft-Contributed to outcome
3. Aircraft-Aircraft systems-Landing gear system-Landing gear actuator-Malfunction - C
Narrative
On August 23, 2012, about 1630 Pacific daylight time (PDT), a Piper PA-30 B, N222BP, made a gear up landing at Scappoose Industrial Airpark, Scappoose,
Oregon. The owner/pilot was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The private pilot was not injured; the
airplane sustained substantial damage to the underbelly structure during the landing on the grass next to runway 33. The cross-country personal flight departed
Vancouver, Washington, about 1600. Visual meteorological conditions prevailed, and no flight plan had been filed.
The pilot reported that prior to landing, he lowered the landing gear, but it would not fully extend. He attempted to manually extend the gear but was
unsuccessful. The pilot determined that due to his low fuel state he would perform a gear up landing. He elected to land on the soft infield grass adjacent to
runway 33 versus on the runway itself in an attempt to minimize the damage to the airplane.
After recovery of the airplane, it was determined that the lower fuselage had sustained substantial damage to the structure as a result of the soft ground ripping
the aluminum sheet metal and belly frame structure. The airplane was secured for further examination of the landing gear.
The airplane was examined by maintenance personnel and an inspector from the Federal Aviation Administration (FAA). During the examination, it was found
that there was a failure of the landing gear transmission assembly, which prevented the extension of the nose landing gear. The landing gear transmission
assembly was replaced, but the damaged assembly was not retained for further testing due to a miscommunication with the repair facility.
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05/27/2013 1805 EDT Regis# N4489F
Macon, GA
Apt: Middle Georgia Regional MCN
Acft Mk/Mdl PIPER PA-32R-300-32R-76804
Acft SN 32R-7680452
Acft Dmg: DESTROYED
Acft TT
Fatal
Opr Name: FLEBO AIR LLC
Opr dba:
5918
2
Ser Inj
0
Aircraft Fire: GRD
Events
1. Emergency descent - Powerplant sys/comp malf/fail
Narrative
HISTORY OF FLIGHT
On May 27, 2013, about 1805 eastern daylight time, a Piper PA-32R-300, N4489F, was destroyed following a collision with terrain while on approach to the
Middle Georgia Regional Airport (MCN), Macon, Georgia. The airline transport pilot and pilot-rated passenger were fatally injured. The airplane was registered to
a corporation and was operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological
conditions prevailed and an instrument flight rules flight plan was filed for the flight that departed Apalachicola Regional Airport (AAF), Apalachicola, Florida,
destined for Greenville Downtown Airport (GMU), Greenville, South Carolina.
A review of the Federal Aviation Administration (FAA) air traffic control (ATC) transcription revealed that the pilot requested to make a precautionary landing at
MCN due to a low oil pressure indication. The controller issued a clearance to MCN airport, assigned a 360 degree heading for a modified left base for a visual
approach (VA) to runway 23 and cleared the aircraft to 3,000 feet. The controller advised the pilot to expect a VA to runway 23 and issued both the wind and
altimeter settings. Personnel at Robins Air Force Base (WRB), Warner Robins, Georgia, were also advised of the airplane's position and the request to
transition WRB airspace for landing at MCN, which was approved. After the pilot reported MCN in sight and as the flight was approximately 5 miles south of
MCN, the controller cleared pilot for the VA to runway 23. Before switching the aircraft to MCN tower, the controller offered further assistance, to which the pilot
replied, "not at this time."
On initial contact with MCN, the pilot advised that his engine had lost all power and he was not going to make it to runway 23. The MCN local controller (LC)
offered runway 31 for a straight in approach; however, the pilot requested landing on runway 15 at WRB. The MCN LC coordinated with WRB and advised the
pilot to contact WRB tower. The pilot never established communication with WRB and the airplane crashed approximately 0.8 mile northeast of WRB, which
was 3 miles southeast of MCN. Smoke was seen from WRB tower and verified by an airborne aircraft that was in the vicinity of the accident airplane.
PILOT INFORMATION
The pilot, age 58, held an airline transport pilot certificate for airplane single-engine land, airplane multiengine land, and instrument airplane ratings; flight
instructor, airplane single engine with a rating for instrument airplane. The pilot reported his total flight experience as 10,050 hours, including 120 hours in last
six months on his FAA medical certificate application, dated August 17, 2004. At that time, the pilot was issued a second class limited medical certificate with
waivers for corrective lenses. The pilot's flight logbook was not available for review.
The four-seat, low-wing airplane, serial number 32R-7680452, was manufactured in 1976. It was powered by a Lycoming model IO-540-K1G5D, 300-hp engine
equipped with Hartzell HC-C3AYR-1RF three bladed propeller. A review of copies of maintenance logbook records showed an annual inspection was completed
on August 16, 2012, at a recorded engine tachometer time of 1750.7 hours and a total airframe time of 5917.8 hours. A review of FAA Airworthiness Directive
(AD) compliance records revealed that AD 95-26-13, oil cooler hose replacement, was complied with on May 11, 2006, and on the last annual inspection that
was complied with, this AD was 354.3 hours overdue and not accomplished. Upon further review of the engine overhaul AD compliance log, it revealed that AD
02-12-07, oil filter converter plate gasket, was complied with on April 22, 2002. The AD was not effective until July 03, 2002, and the engine overhaul log did not
show that this AD was accomplished at that time and there was no record in any log book showing that it was accomplished.
The recorded weather at the WRB, at an elevation of 294 feet, revealed that at 1758, conditions included wind from 150 degrees at 4 knots, clear sky,
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temperature 30 degrees Celsius (C), dew point 17 degrees C, and altimeter setting 30.12 inches of mercury.
The wreckage was located about .8 miles north of the runway 15 threshold, in a heavily wooded swamp. The airplane came to rest upright at the base of a
stump, in a flat attitude, on a course of about 275 degrees. The cockpit, forward cabin, and left wing were damaged by a post-crash fire. No tree strikes were
observed south of the main wreckage and all flight control surfaces were located within the wreckage area.
An examination of the cockpit section revealed that the rudder pedal assembly separated from the structure and sustained fire damage. Both rudder cable
attachment levers were broken from the tube at the weld point. One rudder cable with the attached lever was recovered with the wreckage and the second
cable and lever was not located.
The control column assembly separated from the aircraft and was fire damaged. Both control wheel assemblies remained attached to the upper tee bar section.
The tee bar assembly sustained impact damage. The aileron chains were not attached to the sprockets. The forward aileron cables and chain assemblies were
imbedded within the molten metal of the fire-damaged cockpit. The lower tee bar section separated from the upper bar assembly. Both stabilator cables
remained attached to the lower tee bar assembly. Both cables were cut about 2 feet from their attachment points on the bar assembly for recovery.
The fuel selector valve assembly separated from the fuselage structure and sustained fire damage. The fuel bowl was fire damaged and no fuel was present.
The valve was observed to be in the right fuel tank position, but was not in its detent.
The nose landing gear assembly remained partially attached to the engine mount assembly. The lower gear assembly separated from the upper strut housing.
The position of the nose landing gear could not be determined due to impact and fire damage.
An examination of the left wing revealed that it was separated from the fuselage at the wing root. The wing broke into two sections between the flap and aileron
surfaces. The wing sustained post-crash fire damage mainly to the outboard side of the outboard fuel tank out to the tip. The fuel cap remained attached to the
outboard fuel tank. The inboard fuel tank separated from the wing and was destroyed by fire. The aileron surface remained attached to the wing by its inboard
hinge. No fire damage was noted on the aileron surface. The aileron cables remained attached to the aileron bellcrank assembly. The bellcrank remained
attached to the wing and was undamaged. The aileron cables exhibited overload type separation in the wing root area. The flap surface remained attached to
the wing. The surface revealed impact damage and the position of the flap could not be determined due to separation of the flap torque tube assembly. The left
main landing gear assembly remained attached to the wing and was in the retracted position.
An examination of the right wing revealed that is was separated from the fuselage at the wing root. The wing was partially consumed by the post-crash fire.
Both fuel tanks were fire damaged and destroyed. The outboard fuel tank cap remained attached to the tank. The flap surface remained attached to the wing
but it sustained impact and fire damage. The position of the flap could not be determined due to separation of the flap torque tube assembly. The aileron
surface separated from the wing and was impact damaged. The aileron did not exhibit fire damage. The aileron cables remained attached to the aileron
bellcrank assembly. The bellcrank separated from the wing and both arms of the bellcrank were bent. The aileron cables exhibited overload type separation
signatures in the wing root area. The right main landing gear remained attached to the wing and was in the retracted position. The gear assembly was fire
damaged.
An examination of the empennage section revealed it was separated from the cabin area due to the post-crash fire. The rear empennage was intact and all
movable control surfaces remained attached. The left horizontal stabilizer sustained leading edge impact damage on its inboard section. The right horizontal
stabilizer tip was bent upwards, outboard of the trim tab. The rudder remained attached to the vertical fin and was impact damaged. The forward vertical fin and
fairing sustained impact and fire damage. Both left and right rudder control cables remained attached to the rudder horn. Both stabilator control cables remained
attached to the balance weight arm assembly.
An examination of the engine revealed the crankcase was fractured in the areas of the numbers 4, 5, and 6 cylinders. A visual inspection through the case
openings showed impact damage to the interior surfaces. The camshaft was fractured in the area above the numbers 5 and 6 cylinders. The numbers 4, 5, and
6 connecting rods were separated from the crankshaft. The numbers 1, 2, and 3 connecting rods remained attached to the crankshaft. The number 3
connecting rod was free to rotate on the crankshaft rod journal. The numbers 1 and 2 rods rotated on the journals and the number 3 rod bearing was
unremarkable. The numbers 1 and 2 rod bearings exhibited wiping, scoring and extrusion of the bearing material. The front main crankshaft bearing was
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unremarkable. The numbers 2 and 3 main bearings exhibited wiping, scoring and extrusion of bearing material. The rear main bearing exhibited wiping, scoring
and thermal discoloration. The accessory case was melted on the right side of the oil filter mounting boss. The accessory case and the oil filter mounting plate
were sent to the NTSB Materials Laboratory for further evaluation. The hydraulic hose fitting which attached the hose from the right oil cooler to the accessory
case near the oil filter was fractured. The separated portion of the fitting and the hose were sent to the NTSB Materials Laboratory for further evaluation.
Material consistent in appearance with portions of connecting rods, rod caps, rod bolts, rod bolt nuts, tappet bodies, bearing material and a camshaft lobe were
observed in the oil sump.
Oil was observed inside the engine. About 1 pint was drained from the engine when it was mounted vertically for disassembly. The oil sump was removed and
contained a small amount of oil and debris, consistent with bearing material, tappet body material, connecting rod material and a portion of the camshaft. The
oil suction screen was almost completely obstructed by metallic debris, both ferrous and non-ferrous. The oil filter paper element was charred and exhibited a
smaller amount of metallic debris. The oil coolers remained attached to the rear engine baffling and no breach in the cooler surfaces was identified. The oil
cooler hoses exhibited fire damage. Examination of the oil pump revealed the gears were intact and no anomalies were noted.
An examination of the fuel injector servo revealed that it remained attached to the engine and was discolored and fire damaged. The throttle and mixture cables
remained attached to the throttle and mixture control arms. The fuel servo inlet screen was removed and no debris was noted.
The fuel manifold flow divider remained attached to the engine and was fire damaged. The rubber diaphragm was deteriorated and partially melted. The
one-piece fuel injector nozzles were removed. The nozzle from the number 5 cylinder was obstructed with molten metal debris. The remaining nozzles were
unobstructed. The engine driven fuel pump remained attached to the engine and was partially fire damaged. All fuel hoses forward of the fire were fire
damaged.
The propeller remained attached to the crankshaft flange and the propeller spinner was crushed. The blades were marked A, B and C to differentiate between
the three blades. Blade "A" was bent aft about 5 degrees, about 6 inches outboard of the hub. Blade "B" was curved aft about 10 degrees, about 18 inches
outboard of the hub. Blade "C" was curved aft about 90 degrees, about 18 inches outboard of the hub. Blade "C" was fire damaged and partially melted. The
propeller governor remained attached to the engine and the control cable remained attached to the governor control arm. The governor was removed and no
debris was noted in the governor oil screen.
An autopsy was performed on the pilot by the Georgia Bureau of Investigation, Decatur, Georgia. The autopsy report noted the manner of death as "multiple
blunt trauma."
Toxicological testing was performed on the pilot by the FAA Bioaeronautical Science Research Laboratory, Oklahoma City, Oklahoma. Review of the toxicology
report revealed that no drugs were detected in body cavity blood.
An autopsy was performed on the pilot rated passenger by the Georgia Bureau of Investigation, Decatur, Georgia. The autopsy report noted the manner of
death as "multiple blunt trauma."
Toxicological testing was performed on the pilot rated passenger by the FAA Bioaeronautical Science Research Laboratory, Oklahoma City, Oklahoma. Review
of the toxicology report revealed that no drugs were detected in body cavity blood.
TEST AND RESEARCH
On June 7, 2013, the accessory case cover with oil filter mounting plate, hose fitting and oil hose were examined at the NTSB Materials Laboratory.
The fitting on the crankcase side of the hose was fractured. A bench binocular microscope examination of the hose revealed the fractured fitting contained a
slant fracture that extended completely around the fitting. The fracture face exhibited a rough texture consistent with overstress separation with no evidence of
fatigue cracking. An adapter was attached to the fractured fitting. The exposed end of the adapter contained an external thread. The external thread portion was
covered with solidified metal. The mating internal threads located on the accessory case and accessory case in the general area of the internal threads was
severely deformed from exposure to the post-crash fire. Close examination of the adapter revealed the corner adjacent to the external threads and in the area
below the solidified metal contained material exhibiting size and contour consistent with a gasket.
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07/16/2014 1745 EDT Regis# N297AS
Acft Mk/Mdl PIPER PA-32R-301T
Acft SN 3257122
Eng Mk/Mdl LYCOMING TIO-540-AH1A
Opr Name: GREGG HOWARD
North Captiva I, FL
Apt: Salty Approach FL90
Fatal
1
Ser Inj
Opr dba:
0
Aircraft Fire: NONE
AW Cert: STN
Events
1. Prior to flight - Aircraft loading event
Narrative
HISTORY OF FLIGHT
On July 16, 2014, about 1745 eastern daylight time, a Piper PA-32R-301T, N297AS, was substantially damaged when it impacted the water near North Captiva
Island, Florida. The airplane departed from Page Airport (FMY), Ft. Myers, Florida about 1735 with an intended destination of Salty Approach Airport (FL90), Ft.
Myers, Florida. Day, visual meteorological conditions prevailed and no flight was filed. The private pilot was fatally injured. The personal flight was conducted
under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91.
Numerous witnesses reported that the airplane appeared to be departing from FL90. Some of those accounts stated that the airplane "was having a hard time
trying to climb" or "that it appeared that the pilot was trying to build up speed to gain elevation" prior to the left wing making contact with the water. One
eyewitness, who was familiar with the pilot, reported that the pilot had flown in earlier in the afternoon with a load of tile and the accident flight was the second
trip for the day. Another eyewitness reported that the airplane appeared to be "taking off attempting to recover [from] an aborted landing and did not have the
airspeed to recover." Several of the witnesses reported that they audibly observed the engine operating at the time of the accident. Some of the witnesses
reported the airplane was about 7 feet above the ground when it passed over the beach.
According to Federal Aviation Administration (FAA) records, the pilot held a private pilot certificate for airplane single-engine land with a rating for instrument
airplane. His most recent third class medical certificate was issued on October 22, 2013. The pilot's flight logbook was located in the forward baggage
compartment of the airplane. The logbook was saturated with water and considerable damage was done to the edge of the logbook; however, some pages were
separated and on the last full page of handwritten entries indicated that the pilot had accumulated 2,018.7 total hours of flight experience. The subsequent page
had four entries of 0.5 hours each, for a total flight experience of 2,020.7 hours; however, those entries were not dated.
According to FAA records, the airplane was issued an airworthiness certificate on December 10, 1999, and was registered to Howard Aviation on June 11,
2007, and the pilot was listed as the "president." It was powered by a Lycoming TIO-540-AH1A engine and driven by a Hartzell propeller model HC-I3YR-1RF.
A review of copies of maintenance logbook records showed an annual inspection was completed on January 13, 2014, at a recorded Hobbs meter reading of
1,225 hours and indicated an engine total time in service of 1,225 hours. The Hobbs hour meter was observed at the accident site and indicated 1267.5 hours.
The 1745 recorded weather observation at FMY, located approximately 20 miles to the east of the accident location, included wind from 330 degrees at19
knots with gusts of 30 knots, visibility 1 3/4 miles with thunderstorms in the vicinity and light rain, scattered clouds at 2,400 feet above ground level (agl),
broken clouds at 3,400 feet agl, overcast at 5,500 feet agl, temperature 26 degrees C, dew point 23 degrees C and barometric altimeter 29.99 inches of
mercury. The remarks section included a peak wind at 1741, lightning in all quadrants surrounding the airport, rain began at 1745 and a thunderstorm was
present between 1727 and 1744.
No witnesses or first responders reported lighting, rain, or adverse winds in the vicinity of FL90 at the time of the accident.
AIRPORT INFORMATION
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The airport was privately owned and at the time of the accident did not have a control tower. There was one runway designated runway E/W. The turf runway
was 1,800 feet long and 100 feet wide. The airport was about 6 feet above mean sea level and had a sandy beach area located at both ends of the runway.
The airplane was located in 8 to 10 feet of water, approximately 200 yards west-southwest of the extended centerline of the runway designated "W." The main
wreckage was located at coordinates 26:36'215N 082:13.640W. The airplane was resting its left side on the sea floor. The left wing separated during the impact
sequence and was originally found at coordinates 26:35'250N 082:13.670W. The engine remained attached to the airplane and was collocated with the main
wreckage. The airplane came to rest on a magnetic heading of approximately 340 degrees.
The airplane was recovered utilizing three lifting air bags. During recovery the tie straps damaged the right wing in the vicinity of the aileron. The stabilator and
left wing could not be located utilizing sonar or visual sighting.
Post recovery examination of the wreckage and witness statements indicated that the airplane impacted the water in a left wing low attitude. The fuselage was
placed on a hangar floor for the examination. The right wing was removed to facilitate transportation and the left wing was not located at the accident location.
The nose gear as viewed was in the nose wheel well; however, the hydraulic extension ram was extended and bent aft during the accident sequence. The right
main landing gear was impact-separated at the attach point; however, the hydraulic ram was extended 8 inches, correlating to the right main landing gear being
extended and locked at the time of impact. The flap jackscrew was measured at 3 exposed threads, which correlated to a flaps 40 position or fully extended
position.
Porcelain tiles and two wooden pallets were located, unsecured in the cabin section of the airplane. The tiles and pallets were removed and weighed, on a
scale; the contents weighed a total of 666 pounds. A placard located on the aft wall of the cargo compartment indicated that 609 pounds was the maximum
allowed cargo weight.
Fuselage
The fuselage remained intact; the left cargo/passenger door remained attached, had an approximate 8 inch gouge just aft of the forward hinge point, and the
cabin had a gouge on the roof approximately 6 inches above the pilot, or left side, window. The windows remained in position; except for the pilot side
windscreen and pilot side window, which were not located. The forward cabin door remained attached and during recovery the locking mechanism operated
normally; however, during post recovery examination the door was slightly ajar and would not lock into position. The airplane was equipped with two front seats;
the four aft passenger seats were removed sometime prior to the accident flight. The pilot seat exhibited torsional twist to the left, similar to the torsional twist of
a mass in place at the time of impact. Both seats remained on their respective seat tracks and locked in place. Seat restraints were located and all were
unremarkable, operated normally with no abnormalities noted and exhibited no web stretching. The two front seatbelts were unlatched when found. No cargo
securing mechanism was noted in the accident aircraft other than the passenger seatbelts and a single cargo strap that were found folded and stowed inside
the aircraft.
Cockpit
The instrument panel remained attached and the "L Mag" and "R Mag" switch on the ceiling were in the "ON" position. All instrumentation remained attached
and the turn and bank indicator indicated a left bank turn. The control "T"-bar and the sprockets and chains remained attached; however, binding was noted at
the base of the "T"-bar. Removal of the channel cover indicated that the floor had a slight buckling and manipulation of the buckling allowed the control cables
to operate. Control cable continuity was traced to all the cable breaks from the associated attach points and the breaks had the appearance of broomstrawing
at the fracture points. The right side aileron balance cable was cut to facilitate transport to the salvage yard. The fuel selector valve indicator and fuel selector
valve both indicated that the right fuel tank was selected. The throttle, mixture, and propeller levers were in the full forward positions. The throttle was operated
and was confirmed operating through the full arc of operation at the throttle linkage. The fuel pump and air-conditioner switches were found in the "OFF"
positions. The landing gear lever was in the "DOWN" position and the gear switch was bent to the right. The flap handle was in the "40 degree" or full flap
position.
Empennage
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The vertical fin and rudder remained attached; however, the stabilator was impact-separated from the fuselage and was not recovered. The impact damage
was consistent with overload fractures. The rudder was attached to the vertical fin at its hinge points and control cable continuity was confirmed to the rudder
pedals. The stops were in place and exhibited no peening. The rudder balance weight was located in the rudder assembly. The rudder position at impact could
not be determined.
The stabilator was separated from its mounting. The fracture points were consistent with being separated in an aft and right direction. The stabilator trim drum
was absent and not located.
Left Wing
The left wing was impact separated and was not located. However, the attach structure exhibited overload fractures in the aft and positive direction. The
primary balance cable was fractured and exhibited tensile overload signatures. Control continuity was established to the fracture point.
Right Wing
The right wing remained attached to the fuselage. The wing was unremarkable, except for the damage that resulted from the recovery of the airplane. The right
main landing gear was impact separated at the attach fitting; however, considering the hydraulic ram position of 8 inch, the landing gear was determined to be
in the down and locked position. The flap remained attached to the wing and on the flap track; however, the exact position could not be determined except by
utilizing the exposed threads under the floor in the cabin section. The aileron remained attached and was operated by the control cables, which were cut to
facilitate transport, and revealed no anomalies. The aileron balance weight was in position and attached to the outboard section of the aileron. The fuel tank
contained 15 gallons of blue fluid similar in color and smell as aviation 100LL fuel. The fuel cap was tight and secure and no water was present in the fuel when
drained to facilitate recovery. A small hole was punctured by investigators into the forward section of the tank to facilitate draining of the fuel into containers.
The wing tip remained attached.
Engine
The engine remained attached to the airframe via the mounts, cables, and wires. The propeller remained attached to the propeller hub, which remained
attached to engine. The fuel inlet screen was removed and was free of debris. The fuel injectors were removed from the engine and a partial obstruction was
observed in all injectors, however, utilization of low air pressure air removed the obstructions. All lines from the divider and vent return were intact. The
turbocharger remained attached to the engine; the impeller rotated smoothly by hand and exhibited soft or minor damage to two of the impeller blades. An
undetermined quantity of oil was observed in the turbocharger drain back tank. The turbocharger waste gate operated smoothly with no abnormalities noted. All
ignition leads were intact and secured to the spark plugs. The top and bottom spark plugs were removed and appeared normal in wear and slightly dark in color.
The bottom sparkplugs were wet with oil, which was consistent with the at-rest position of the engine. The engine was rotated utilizing the propeller through the
propeller hub and continuity was confirmed to the right rear magneto pad and the magneto impulse coupling was audibly observed to be actuating. Thumb
suction and compression was confirmed on all six cylinders. The magnetos were removed and were spun utilizing a cordless drill; however, no spark was
observed. The left and right magnetos remained attached to the engine. The engine driven fuel pump was removed and the shaft remained intact. The vacuum
pump was removed and rotation was accomplished by hand with suction noted at the intake fitting. The oil dipstick was present and oil was observed on the oil
dipstick; however, an accurate quantity could not be determined. The density control and pop off valves remained attached to the engine. The oil filter was
removed, cut open, and was free of metallic particulates. The air/oil separator was removed and examined, revealing oil was present in the screen and a
minimal amount of debris was noted.
No obstructions were observed in the exhaust crossover section.
Propeller
The Hartzell 3-bladed propeller exhibited S-bending and tip curling on all blades. All three propeller blades were bent in the aft direction between 17 and 19
inches from the propeller hub. The propeller governor remained attached to the engine and operated with no abnormalities noted.
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An autopsy was performed on the pilot on July 19, 2014 by District 21, State of Florida, Office of the District Medical Examiner. The cause of death was listed
as "Drowning."
Forensic toxicology was performed on specimens from the pilot by the FAA Bioaeronuatical Sciences Research Laboratory, Oklahoma City, Oklahoma. The
toxicology report revealed the following:
96 (mg/dl, mg/hg) Ethanol detected in Liver
46 (mg/dl, mg/hg) Ethanol detected in Muscle
N-Propanol detected in Liver
N-Propanol detected in Muscle
Additionally, putrefaction (which consists of the post-mortem creation of ethanol) was noted as yes. The report further stated that no drugs were detected in the
liver.
CFR Part 91.9(a) states, "Except as provided in paragraph (d) of this section, no person may operate a civil aircraft without complying with the operating
limitations specified in the approved Airplane or Rotorcraft Flight Manual, markings, and placards, or as otherwise prescribed by the certificating authority of the
country of registry."
Pilots Handbook of Aeronautical Knowledge (FAA-H-8083-25A)
Section 4 "Aerodynamics of Flight" states "The CG [center of gravity] range is very important when it comes to stall recovery characteristics. If an aircraft is
allowed to be operated outside of the CG, the pilot may have difficulty recovering from a stall. The most critical CG violation would occur when operating with a
CG which exceeds the rear limit. In this situation, a pilot may not be able to generate sufficient force with the elevator to counteract the excess weight aft of the
CG. Without the ability to decrease the AOA [angle of attack], the aircraft continues in a stalled condition until it contacts the ground."
The "Glossary" defines CG as "the point at which an airplane would balance if it were possible to suspend it at that point. It is the mass center of the airplane,
or the theoretical point at which the entire weight of the airplane is assume to be concentrated. It may be expressed in inches from the reference datum, or in
percentage of mean aerodynamic chord (MAC). The location depends on the distribution of weight in the airplane."
Advisory Circular (AC) 61-67C "Stall and Spin Awareness Training"
Chapter 1 "Ground Training: Stall and Spin Awareness" states in part "The CG location has a direct effect on the effective lift and AOA of the wing, the amount
and direction of force on the tail, and the degree of stabilizer deflection needed to supply the proper tail force for equilibrium. The CG position, therefore, has a
significant effect on stability and stall/spin recovery. As the CG is moved aft, the amount of elevator deflection needed to stall the airplane at a given load factor
will be reduced.this could make the entry into inadvertent stalls easier.IN an airplane with an extremely aft CG, very light back elevator control forces may lead
to inadvertent stall entries."
Saratoga II TC PA-32R-301T Pilot Operating Handbook (POH)
Section 6 "Weight and Balance" states in part "Misloading carries consequences for any aircraft. An Overloaded airplane will not take off, climb or cruise as
well as a properly loaded one. The heavier the airplane is loaded, the less climb performance it will have. Center of gravity [C.G.] is a determining factor in flight
characteristics. If the C.G. is too far forward in any airplane, it may be difficult to rotate for takeoff or landing. If the C.G. is too far aft, the airplane may rotate
prematurely on takeoff or tend to pitch up during climb. Longitudinal stability will be reduced. This can lead to inadvertent stall and even spins."
Weight and Balance
According to the POH the airplane's maximum gross weight limit was 3600 pounds and the CG envelope was between 78 and 95 inches, depending on the
aircraft weight. The airplane's weight and balance was calculated utilizing the available information for the fuel, pilot's weight at autopsy, cargo distribution, and
airplane configuration. Although it could not be conclusively determined the amount of fuel on board at the time of departure, 15 gallons of fuel was removed
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from the right fuel tank. Assuming that the left fuel tank was devoid of fuel, the airplane would have weighed approximately 3,547 pounds. The CG Moment
Envelope indicated that the accident airplane's CG may have been near the aft CG limit, but within the envelope. However, it could not be accurately
determined how the tiles were distributed in the cabin. If the tiles were loaded in, or shifted to, the forward section of the cargo compartment the CG could have
been as far forward as 91.56 inches. If the tiles were loaded in, or shifted to, the aft section of the cargo compartment then the CG could have been as much
as 98.93 inches or 3.93 inches aft of the most rearward approved CG.
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Incident Rpt# ERA13IA267
06/03/2013 1520 EDT Regis# N633TC
Tallahassee, FL
Acft Mk/Mdl PIPER PA-34-200T
Acft SN 34-7870328
Acft Dmg: NONE
Acft TT
Fatal
Opr Name: FLORIDA FLIGHT TRAINING CENTER
Opr dba:
7424
0
Ser Inj
Apt: Tallahassee TLH
0
Aircraft Fire: NONE
Events
1. Initial climb - Flight control sys malf/fail
Narrative
On June 3, 2013, about 1520 eastern daylight time, a Piper PA-34-200T, N633TC, experienced a trim cable failure during climbout from Tallahassee Regional
Airport (TLH), Tallahassee, Florida. The flight instructor (CFI) and student pilot were not injured, and the airplane was not damaged. Visual meteorological
conditions prevailed and no flight plan was filed. The airplane was registered to and operated by Florida Flight Training Center under the provisions of Title 14
Code of Federal Regulations Part 91 as an instructional flight. The flight was originating at the time of the incident.
The CFI stated they departed from TLH uneventfully and were climbing through 300 feet when the student pilot noticed a problem with the elevator trim wheel.
The CFI moved the trim wheel and noted no resistance when the wheel was turned. Upon looking down at the wheel, he observed the trim cable protruding out
from the side of the wheel. The student pilot advised that he was having difficulty controlling the airplane and the CFI subsequently assumed control of the
airplane. The CFI advised the tower controller of the emergency and landed the airplane without incident. Examination of the airplane revealed that the elevator
trim cable had broken and was protruding from the trim wheel housing.
The elevator trim cable assembly was sent to the NTSB material laboratory for examination. An examination of the trim cable revealed that it was composed of
a 1/16 inch diameter wire rope with a swaged-on ball at one end and a swaged-on turnbuckle fitting at the other end. Visual inspection revealed trim cable
lubrication along the entire length with no indication of external corrosion. The wire rope section had separated about 5 feet 6 inches from the turnbuckle end
and 14 feet 6 inches from the ball end of the cable. The separation was made up of individual wire breaks spread along an approximate 2-inch length of the
wire rope. A magnified visual inspection of the cleaned cable established that all but a few wires were fractured directly across the wires with no apparent
yielding or deformation. Further, only a few wires (broken or intact) showed either internal or external wear. A scanning electron microscope examination of
several of the broken wires revealed features consistent with fatigue progression through the individual wires.
A review of the aircraft logbooks revealed that the failure of the trim cable was not detected on April 25, 2013, -during the 100 hour and annual inspections. Nor
was it noted on April 13, 2013, during the compliance of AD 2013-02-13; which states in section 7-149 a) "At each annual or 100 hour inspection, all control
cables must be inspected for broken wires strands. Any cable assembly that has one broken wire strand located in a critical fatigue area must be replaced."
The inspection was completed 3 months prior to this event.
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03/16/2015 815 MDT
Acft Mk/Mdl PIPER PA18 - 150-150
Regis# N4785F
Boulder, CO
Acft SN 18-7906
Rpt Status: Prelim
Fatal
0
Opr Name: SOARING SOCIETY OF BOULDER INC
Opr dba:
Page 150
Apt: Boulder Municipal KBDU
Ser Inj
Air Data Research
0
Prob Caus: Pending
Aircraft Fire: NONE
All Rights Reserved
Accident Rpt# ANC15CA014
03/08/2015 1200 AKD Regis# N5348T
Acft Mk/Mdl PIPER PA18 - 150-150
Opr Name: TOBY ASHLEY
Page 151
Acft SN 18-8009009
Talkeetna, AK
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire: NONE
All Rights Reserved
03/19/2015 1630 PDT Regis# N8403Y
Acft Mk/Mdl PIPER PA30 - NO SERIES-NO
Acft SN 301552
Eng Mk/Mdl LYCOMING IO-320
Opr Name: ROBERT A BLAIR
Red Bluff, CA
Apt: Red Bluff Municipal RBL
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
0
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: STN
Events
Narrative
On March 19, 2015, about 1630 Pacific daylight time, a Piper PA-30 multiengine airplane, N8403Y, was substantially damaged following a runway excursion
during landing roll at the Red Bluff Municipal Airport (RBL), Red Bluff, California. The certified private pilot, the owner of the airplane, and three passengers
received minor injuries. Visual meteorological conditions prevailed for the personal cross-country flight, which was operated in accordance with 14 Code of
Federal Regulations Part 91, and a flight plan was not filed. The flight originated from the Shelter Cover Airport (0Q5), Shelter Cove, California, at 1530.
The pilot reported that after touching down and during the landing roll, the airplane began to drift to the right. Application of the left rudder pedal and left brake
were unsuccessful in stopping the excursion. The airplane subsequently went off the right side of the runway and down an embankment, where it came to rest
in an upright position. A postaccident inspection revealed that the airplane had sustained structural damage to its undercarriage and nose section.
The airplane was recovered to a secured facility for further examination.
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10/16/2014 1215 CDT Regis# N106C
Acft Mk/Mdl PIPER PA32 301FT-301FT
Acft SN 3232039
Apt: Winona-montgomery County 5A6
Acft Dmg:
Fatal
Eng Mk/Mdl LYCOMING IO-540-K1G5D
Opr Name: KNIGHT BROTHERS INC
Winona, MS
0
Ser Inj
Opr dba:
0
Aircraft Fire:
AW Cert: STN
Summary
The pilot reported that he had maintenance conducted on the airplane's avionics, which included the replacement of the primary flight display (PFD). After the
maintenance was completed, the pilot prepared to return to his home airport. A preflight inspection revealed no anomalies, and the steering system operated
normally during taxi. During the takeoff roll, the pilot observed a red "X" indication over the airspeed indicator on the PFD. He "immediately started an
emergency shutdown" of the airplane, during which the airplane began to drift left. He applied right rudder with no effect. The airplane subsequently departed
the left side of the runway, continued across a grassy area, and impacted the airport perimeter fence, which resulted in substantial damage to the right wing
and engine firewall.
Postaccident examination of the nose landing gear steering system, rudder controls, and brake system revealed no anomalies, and no evidence of flight control
binding or chafing was found. Maintenance facility personnel removed the newly replaced PFD before it could be examined; therefore, it could not be
determined if its installation interfered with the airplane's flight control system. According to the Pilot's Operating Handbook, the emergency procedure for a loss
of air data on the PFD was to maintain airspeed and altitude by referring to the standby airspeed and altimeter.
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10/16/2014 1215 CDT Regis# N106C
Winona, MS
Apt: Winona-montgomery County 5A6
Acft Mk/Mdl PIPER PA32 301FT-301FT
Acft SN 3232039
Eng Mk/Mdl LYCOMING IO-540-K1G5D
Acft TT
Fatal
Opr Name: KNIGHT BROTHERS INC
Opr dba:
1022
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Summary
The pilot reported that he had maintenance conducted on the airplane's avionics, which included the replacement of the primary flight display (PFD). After the
maintenance was completed, the pilot prepared to return to his home airport. A preflight inspection revealed no anomalies, and the steering system operated
normally during taxi. During the takeoff roll, the pilot observed a red "X" indication over the airspeed indicator on the PFD. He "immediately started an
emergency shutdown" of the airplane, during which the airplane began to drift left. He applied right rudder with no effect. The airplane subsequently departed
the left side of the runway, continued across a grassy area, and impacted the airport perimeter fence, which resulted in substantial damage to the right wing
and engine firewall.
Postaccident examination of the nose landing gear steering system, rudder controls, and brake system revealed no anomalies, and no evidence of flight control
binding or chafing was found. Maintenance facility personnel removed the newly replaced PFD before it could be examined; therefore, it could not be
determined if its installation interfered with the airplane's flight control system. According to the Pilot's Operating Handbook, the emergency procedure for a loss
of air data on the PFD was to maintain airspeed and altitude by referring to the standby airspeed and altimeter.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: A loss of directional control
during takeoff for reasons that could not be determined because postaccident examination of the airplane revealed no anomalies.
Events
1. Takeoff-rejected takeoff - Loss of control on ground
2. Takeoff-rejected takeoff - Runway excursion
3. Environmental issues-Physical environment-Object/animal/substance-Fence/fence post-Contributed to outcome
Narrative
On October 16, 2014, about 1215 central daylight time, a Piper PA32-301FT, N106C, was substantially damaged during an aborted takeoff at
Winona-Montgomery County Airport (5A6), Winona, Mississippi. The private pilot was not injured. Visual meteorological conditions prevailed, and no flight plan
was filed for the personal flight, which was operated under the provisions of Title 14 Code of Federal Regulations Part 91.
The pilot stated that he flew the airplane to 5A6 so that maintenance could be conducted on the airplane's avionics. After completion of the maintenance, the
pilot conducted a preflight inspection, started the engine, and taxied to the runway in preparation for departure. Neither the preflight inspection nor pre-takeoff
checks revealed any anomalies with the airplane. During the takeoff roll, the pilot observed a red X indication over the airspeed indicator on the PFD, and
"immediately started an emergency shutdown." He stated that the airplane began drifting to the left, and he applied right rudder to correct, but the airplane was
unresponsive. The airplane continued off the left side of the runway and into the grass, where it impacted the airport perimeter fence, resulting in substantial
damage to the engine firewall and right wing.
Review of records provided by the maintenance facility revealed that the airplane's PFD was replaced, and the multifunction display (MFD) software card was
upgraded in accordance with a manufacturer's service bulletin. The airplane also received altimeter system and transponder tests, fuel system calibration, and
compass calibration, and was subsequently returned to service.
The 1153 weather observation at Greenwood-Leflore Airport (GWO), Greenwood, Mississippi, located about 18 nautical miles west of the accident airport,
included wind from 270 degrees at 5 knots, 10 miles visibility, temperature 21 degrees C, dew point 7 degrees C, and an altimeter setting of 30.01 inches of
mercury.
The pilot held a private pilot certificate with a rating for airplane single-engine land. His most recent flight review was conducted in January 2014. His most
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recent third class Federal Aviation Administration (FAA) medical certificate was issued in August 2013. He reported 190 total hours of flight experience, of
which 110 hours were in the accident airplane make and model.
The airplane was manufactured in 2005, and registered to the pilot in November 2013. Its most recent annual inspection was completed in May 2014. At the
time of the accident, the airplane had accumulated 1,021.8 total hours. According to manufacturer and FAA airworthiness records, the airplane was equipped
with a standby airspeed indicator, altimeter, and attitude indicator.
The airport was equipped with a single asphalt runway, in a 03/21 configuration. The runway measured 4,000 feet long by 60 feet wide.
The airplane was examined at the accident site by an FAA inspector. He observed substantial damage to the right wing and engine firewall. The airplane was
then recovered from the site for further examination; however, before the examination could be conducted, the maintenance facility removed the
newly-replaced PFD unit.
Follow-up examinations by the FAA inspector established flight control continuity from the rudder pedals to the rudder. There was no evidence of binding or
chafing of the flight controls indicative of control interference. No anomalies of the braking system were observed. The airplane was placed on jacks to facilitate
inspection of the nose landing gear steering system. The left steering rod remained attached at the steering yoke, and the right steering rod had been
disconnected from the steering yoke by recovery personnel. The steering yoke was separated from the nose landing gear strut at impact, and the bolts were
sheared.
According to the pilot's operating handbook, the emergency procedure for a loss of air data on the PFD was:
"Maintain aircraft airspeed and altitude by referring to the standby airspeed and altimeter.
If time and conditions permit: PFD Circuit Breaker....PULL and RESET
If air data is still invalid: Refer to standby airspeed indicator and altimeter. Land as soon as practical."
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08/25/2013 1406 EDT Regis# N720JF
Cat Cay, FN BF
Apt: Cat Cay Airport MYCC
Acft Mk/Mdl PIPER AIRCRAFT INC PA46R-350T
Acft SN 4692004
Eng Mk/Mdl LYCOMING TIO-540-AE2A
Acft TT
Fatal
Opr Name: PURE BEAUTY FARMS INC
Opr dba:
1000
0
Ser Inj
0
Aircraft Fire: NONE
Events
1. Initial climb - Loss of engine power (total)
Narrative
HISTORY OF FLIGHT
On August 25, 2013, about 1406 eastern daylight time, a Piper PA46R-350T, N720JF, impacted the water immediately after takeoff from the Cat Cay Airport
(MYCC), Cat Cay, Bahamas. The airline transport pilot and four passengers received minor or no injuries. The airplane sustained substantial damage to both
wings. The airplane was registered to, and operated by, Pure Beauty Farms under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal
flight. Visual meteorological conditions prevailed in the area and no flight plan had been filed for the flight destined for the Kendall-Tamiami Executive Airport
(KTMB), Miami, Florida.
Under the provisions of Annex 13 to the Convention on International Civil Aviation and by mutual agreement, the Air Accident Investigation & Prevention Unit
(AAIPU) delegated the accident investigation to the government of the United States. The AAIPU did not designate an accredited representative to the
investigation.
According to the pilot, after the airplane was aligned with the center of the runway, he applied full power; confirmed the manifold pressure, rpm, fuel flow, and
that the flaps were at the 10 degree flap setting. After the brakes were released for takeoff he confirmed that all of the systems were "in the green." At an
airspeed of about 80 knots the airplane became airborne, subsequently, about 150 feet above ground level the airplane's engine "stopped" and the pilot lowered
the nose. The airplane impacted the water in a flat pitch attitude and came to rest in about 6 feet of water.
According to two of the passenger's written statements, the airplane taxied down the runway, turned around, and departed. Within a few seconds after
departure the airplane impacted the water and a sandbar a few hundred feet from the runway. None of the written passenger statements mentioned the engine
stopping or losing power.
The pilot, age 69, held an airline transport pilot certificate for airplane single-engine and multiengine land, a flight instructor certificate for airplane single-engine
and multiengine, and a second-class airman medical certificate issued June 2, 2011. The pilot reported 12,250 total flight hours, with 210 hours in the accident
aircraft make and model.
The six-seat, low-wing, retractable gear airplane, was manufactured in 2008. It was powered by a Lycoming TIO-540-AE2A 350-hp engine and equipped with a
3-blade Hartzell model HC-13YR-1E constant speed propeller. According to the airplane's maintenance records, the most recent annual inspection was
completed August 2, 2013, at a recorded Hobbs meter reading of 999.5 hours and an engine total time in service of 999.5 hours.
The 1353 recorded weather observation at, Ft. Lauderdale-Hollywood International Airport (KFLL), Fort Lauderdale, Florida, located about 56 miles from the
accident location, included wind from 070 degrees at 11 knots, 10 miles visibility, scattered clouds at 2,200 feet above ground level (agl) and broken clouds at
11,000 feet agl, temperature 28 degrees C, dew point 23 degrees C; barometric altimeter 30.11 inches of mercury. According to the pilot, the wind at the
departure airport was from 120 degrees at 5 knots.
AIRPORT INFORMATION
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According to information provided by the Bahamas' Civil Aviation Training Department, the airport was a privately owned airport and at the time of the accident
did not have an operating control tower. The airport was equipped with one runway, designated 14/32. The runway was 1,300 feet long, 75 feet wide, and the
surface was listed as "aggregate." The runway dimensions were measured in Google earth and were similar as those provided by the Bahamas' Civil Aviation
Training Department. According to photographs provided by the Royal Bahamas Police Force, the airport was about 3 feet above mean sea level. The pilot
reported the runway length as 1,900 feet.
According to photographs provided by the AAIPU of The Bahamas and the Royal Bahamas Police Force, the airplane came to rest in shallow water, about 300
feet from the end of the runway. The nose and right wing were submerged in the water and the fuselage extended above the water surface. The left wing was
partially separated at the wing root and exhibited impact marks along the leading edge. The main landing gear was in the extended, or in the down position, and
the flaps were extended; however, an exact flap position could not be ascertained.
The airplane was equipped with an Avidyne Multi-Function Display (MFD) and an Avidyne Primary Flight Display (PFD). The units were removed by aircraft
recovery personal and sent to the NTSB Vehicle Recorders Laboratory, Washington, DC for data retrieval.
The MFD unit contained a Compact Flash (CF) card which contained checklist approach charts, map information, and the flight log data. During operation, the
MFD receives GPS position, time and track data, as well as altitude, engine, electrical system parameters, and outside air temperature. The MFD data was
sampled every 6 seconds and was recorded to memory once every minute. The CF card contained 78 recorded events including the accident event.
The PFD unit consisted of an air data and altitude heading reference system and displays aircraft flight data including altitude, airspeed, vertical speed, and
heading. The data was recorded at various rates. The PFD contained several recorded events including the accident flight.
Examination of the data parameters revealed an abrupt spike consistent with an impact at 1405:57. At 1405:48, the data indicated a 0 pitch attitude and the
1405:50 data recorded a pitch attitude of about 17 degrees nose up attitude. However, at 1405:52 the data indicated a 17 degree left roll, a pitch up to about 20
degrees, followed by a roll to the right of 77 degrees right wing down and a nose down pitch attitude of about 50 degrees. The engine data from the MFD
contained parameters such as fuel flow, RPM, and Cylinder Head Temperatures; however the MFD stopped recording at 1405:51. From 1405:30 until the end
of the recording, the recorded data indicated the inlet temperature was about 1250 degrees F, oil pressure was about 85 psi, RPM was 2500, manifold air
pressure was about 37 inches of mercury, and the fuel flow was about 38 gallons per hour. Which, according to the Pilot Operating Handbook, are all
considered to be in the "Green Arc" or the "Normal Operating Range." According to data extracted from the PFD, the highest recorded airspeed occurred at
1405:56, which indicated 70.3 knots.
The engine was examined by NTSB personnel. Photographs taken of the engine revealed external corrosion and an internal examination revealed corrosion,
similar to salt water intrusion. However, there was no conclusive indication of mechanical abnormalities that would have precluded normal operation.
Pilot's Handbook of Aeronautical Knowledge (FAA-H-8083-25A)
Section 4 "Aerodynamics of Flight" states in part "The stalling speed of a particular aircraft is not a fixed value for all flight situations, but a given aircraft always
stalls at the same AOA [Angle of Attack] regardless of airspeed, weight, load factor, or density altitude. Each aircraft has a particular AOA where the airflow
separates from the upper surface of the wing and the stall occurs. This critical AOA varies from 16 degrees to 20 degrees depending on the aircraft design. But
each aircraft has only one specific AOA where the stall occurs."
Pilot Operating Handbook
According to Section 4 "Normal Procedures," there were several different types of takeoff procedures; which required different flap settings, liftoff speed, and
climb speed or obstacle clearance speed. The section titled "Normal Technique" stated in part "When the available runway length is well in excess of that
required and obstacle clearance is no factor, the normal takeoff technique may be used. The flaps should be in the 0 degree to 10 degrees position and the
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pitch trim set slightly aft of neutral. Align the airplane with the runway, apply full power, and accelerate to 80-85 KIAS [Knots Indicated Airspeed]." The section
further stated "Takeoffs are normally made with flaps 0 degree to 10 degrees. For short field takeoffs or takeoffs affected by soft runway conditions or
obstacles, total distance can be reduced appreciable by lowering the flaps to 20 degrees."
Section 5 "Performance" contained a warning that stated "Performance information derived by extrapolation beyond the limits shown on the charts should not
be used for flight planning purposes." The section also contained two charts to determine takeoff ground roll distance. The first chart, "Takeoff Ground Roll
distance - 0 degree Flaps" revealed that, considering the information provided by the pilot, the ground roll would have required about 1,700 feet. The chart
provided "Associated Conditions," which required the wing flaps to be set at 0 degree, full throttle, 2500 RPM prior to brake release, a liftoff speed of 78 knots
indicated air speed (KIAS), and a paved, level and dry runway.
The other chart, "Takeoff Ground Roll Distance - 20 degree Flaps," revealed, under the same conditions, the ground roll would have been about 1,150 feet. The
chart further provided "Associated Conditions" which required the wing flaps to be set at 20 degrees, full throttle, 2500 RPM prior to brake release, a liftoff
speed of 69 KIAS, and a paved, level and dry runway.
Section 5 also provided an "Angle of Bank vs. Stall Speed" chart, and a review of the chart revealed that with the landing gear down, flaps at 20 degree, and a
bank angle of zero the stall speed would be about 65 knots. Then, with the landing gear and flaps both retracted the stall speed would be about 69 knots. The
chart further revealed that at a 17 degree bank angle, the stall speed for landing gear down, flaps at 20 degrees would be about 66 knots and for both the
landing gear and flaps retracted the stall speed would be about 71 knots. There was no stall speed, provided by the chart, for gear down and flaps at 10
degrees.
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01/04/2015 1603 EST Regis# N349EA
Parker City, IN
Apt: Delaware County Regional Airpo MIE
Acft Mk/Mdl RAYTHEON AIRCRAFT COMPANY A36
Acft SN E-3549
Eng Mk/Mdl CONTINENTAL IO-550-B89B
Acft TT
Fatal
Opr Name: ON FILE
Opr dba:
1188
0
Ser Inj
1
Aircraft Fire: NONE
Events
1. Maneuvering - Loss of control in flight
Narrative
On January 4, 2015, about 1603 eastern standard time, a Raytheon Aircraft Company A36 single-engine airplane, N349EA, was substantially damaged after
impacting terrain while maneuvering near Parker City, Indiana. The private pilot, who was the sole occupant, sustained serious injuries. The airplane was
registered to Black Gold Aviation, LLC, Norris City, Illinois, and operated by the pilot. Instrument meteorological conditions (IMC) prevailed at the time of the
accident and an instrument flight rules (IFR) flight plan was filed for the 14 Code of Federal Regulations Part 91 personal flight. The airplane departed from the
Carmi Municipal Airport (CUL), Carmi, Illinois, approximately 1400 central standard time, and was destined for the Delaware County Regional Airport (MIE),
Muncie, Indiana.
According to the pilot, prior to the accident flight, he completed two practice instrument approaches at CUL, then obtained a weather briefing for a flight to MIE.
The airplane departed CUL at 1345 central standard time, and prior to obtaining his IFR clearance, the pilot noted the autopilot would not engage so he returned
to CUL. After landing, the pilot checked the circuit breaker and fuse for the autopilot with no problems noted. The pilot cycled the avionics master switch and
the autopilot was then determined by the pilot to be functioning. The pilot then departed CUL at 1400 central standard time.
At 1549, air traffic control (ATC) instructed the pilot to descend at his discretion from 9,000 feet to 4,000 feet. While performing the descent checklist, the pilot
switched fuel tanks at which time the engine lost power. The pilot stated he was certain the engine restarted and resulted in "putting me behind the airplane in
performing my cockpit duties." The next thing the pilot remembered was ATC informing him he was flying in circles and losing altitude. The pilot felt he was in a
spin and attempted to regain control of the airplane. The airplane broke out of the cloud layer and the pilot recalled it snowing with poor visibility. The pilot
located a harvested cornfield and made the decision to land in the cornfield. The pilot does not recall why he decided to execute an off-airport landing. During
the landing, the airplane impacted terrain and trees.
A witness, who was located near the accident site, reported he observed the airplane at a low altitude traveling at a high rate of speed heading in a northerly
direction. The witness observed the airplane pitch nose up to almost vertical flight, and then turn to a west-southwest heading, before impacting the cornfield.
The airplane impacted terrain, bounced, and impacted trees.
After reflecting on the accident flight, the pilot noted the following for reasons not to perform the flight:
"1. First long flight after annual and doing it in poor weather.
2. Limited flying time due to my end of year work schedule and airplane being in annual for two weeks.
3. The weather I had set myself a minimum of 1,000 feet for shooting approaches (If I recall correctly ceilings at MIE at time of briefing were 1,300, they had
dropped I believe to 850 to 900 feet at time of arrival).
4. Autopilot malfunctioned on first departure; it had never done that before.
5. Should have left fuel tank selector alone, had not used that much fuel."
At 1553, the MIE automated surface observing system reported the wind from 270 degrees at 16 knots, gusting to 25 knots, visibility 3/4 mile, decreasing snow,
mist, sky broken at 1,200 feet, ceiling overcast at 1,800 feet, temperature 0 degrees Celsius, dew point minus 2 degrees Celsius, and an altimeter setting of
30.02 inches of Mercury.
An examination of the airplane by two Federal Aviation Administration inspectors, and technical representatives from Textron Aviation and Continental Motors
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revealed the three propeller blades were twisted and bent aft. The forward fuselage was crushed upward and distorted. The flaps and landing gear appeared to
be in the retracted position. No preaccident mechanical malfunctions or failures were noted with the airplane that would have precluded normal operation.
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11/03/2013 1550 CST Regis# N981PA
Acft Mk/Mdl RAYTHEON AIRCRAFT COMPANY A36
Opr Name:
Page 161
Acft SN E-3599
Hayden, CO
Apt: Yampa Valley KHDN
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire:
All Rights Reserved
03/20/2015 2000 CST Regis# N701CT
Acft Mk/Mdl ROBINSON HELICOPTER
Opr Name: HEIEN BRITT
Page 162
Acft SN 1161
Lake Hamilton, AR
Apt: N/a
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire: NONE
All Rights Reserved
03/22/2015 1430 EDT Regis# N30242
Acft Mk/Mdl ROBINSON HELICOPTER COMPANY R44 Acft SN 11784
Eng Mk/Mdl LYCOMING IO-540-AE1A5
Acft TT
Opr Name: HQ AVIATION LLC
Opr dba:
1268
Orlando, FL
Apt: N/a
Acft Dmg: DESTROYED
Fatal
3
Ser Inj
Rpt Status: Prelim
0
Prob Caus: Pending
Aircraft Fire: GRD
AW Cert: STN
Events
1. Enroute-cruise - Loss of control in flight
Narrative
On March 22, 2015, about 1430 eastern daylight time, a Robinson R44 II helicopter, N30242, impacted a two-story building while maneuvering near Orlando,
Florida. The private pilot and two passengers were fatally injured, and the helicopter was destroyed. The helicopter was registered to a private individual and
operated by HQ Aviation, Orlando, Florida. The local flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. Visual
meteorological conditions prevailed and no flight plan was filed for the personal flight, which departed from Executive Airport (ORL), Orlando, Florida, shortly
before the accident.
Multiple witnesses reported hearing a loud helicopter flying low which caught their attention. As they looked in the direction of the sound they observed the
helicopter descending into a tree canopy. One witness watched the helicopter's main rotor blades break apart as the helicopter descended through the trees.
The helicopter subsequently impacted a power line transformer before it collided with a building and exploded into fire. The witnesses called 911 and attempted
to extinguish the fire.
Preliminary review of air traffic control radar data and voice transcription revealed that the pilot requested a downtown departure. The helicopter departed ORL
on a westerly heading and approximately 5 minutes into the flight the pilot requested to return to the airport. This was the last recorded transmission from the
pilot.
Examination of the accident site by the National Transportation Safety Board (NTSB) investigator-in charge revealed that the helicopter impacted the top of a
two-story building about 3 nautical miles northwest of ORL on a 360 degree magnetic heading. The wreckage debris field was about 50 yards in circumference.
All flight control surfaces were located at the accident site. Examination of the wreckage revealed that a post-impact fire was concentrated within the second
story of the building where the helicopter came to rest.
The cockpit section of the helicopter was destroyed by impact forces and post-crash fire. The main rotor mast, head and gearbox were found within the
wreckage debris field.
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09/10/2014 1326 CDT Regis# N711YM
Austin, TX
Apt: Austin-bergstrom International KAUS
Acft Mk/Mdl SMITH AEROSTAR 601P
Acft SN 61P-0215-023
Acft Dmg: DESTROYED
Eng Mk/Mdl LYCOMING IO-540-S1A5
Acft TT
Fatal
Opr Name: ANDERSON DAVID
Opr dba:
3438
1
Ser Inj
0
Aircraft Fire: GRD
AW Cert: STN
Summary
Witnesses reported observing the airplane flying slowly toward the airport at a low altitude. The left engine was at a low rpm; "sputtering," "knocking," or making
a "banging" noise; and trailing black smoke. One witness said that, as the airplane passed over his location, he saw the tail "kick" horizontally to the right and
the airplane bank slightly left. The airplane subsequently collided with trees and impacted a field 1/2 mile north of the airport.
Disassembly of the right engine revealed no anomalies, and signatures on the right propeller blades were consistent with power and rotation on impact. The left
propeller was found feathered. Disassembly of the left engine revealed that the spark plugs were black and heavily carbonized, consistent with a rich fuel-air
mixture; the exhaust tubing also exhibited dark sooting. The rubber boot that connected the intercooler to the fuel injector servo was found dislodged and
partially sucked in toward the servo. The clamp used to secure the hose was loose but remained around the servo, the safety wire on the clamp was in place,
and the clamp was not impact damaged or bent. The condition of the boot and the clamp were consistent with improper installation. The time since the last
overhaul of the left engine was about 1,050 hours. The last 100-hour inspection occurred 3 months before the accident, and the airplane had been flown only
0.8 hour since then. It could not be determined when the rubber boot was improperly installed. Although the left engine had failed, the pilot should have been
able to fly the airplane and maintain altitude on the operable right engine, particularly since he had appropriately feathered the left engine.
Cause Narrative
sufficient clearance from trees during the single-engine landing approach. Contributing to the accident was the loss of power in the left engine due to an
improperly installed rubber boot that became dislodged and was then partially sucked into the fuel injector servo, which caused an excessively rich fuel-air
mixture that would not support combustion.
Events
1. Approach - Loss of engine power (partial)
2. Approach - Collision with terr/obj (non-CFIT)
1. Aircraft-Aircraft systems-Fuel system-Fuel distribution-Failure - F
2. Personnel issues-Task performance-Maintenance-Installation-Maintenance personnel - C
3. Personnel issues-Psychological-Attention/monitoring-Monitoring environment-Pilot - C
4. Personnel issues-Action/decision-Info processing/decision-Identification/recognition-Pilot - C
6. Aircraft-Aircraft systems-Fuel system-Fuel distribution-Incorrect service/maintenance - F
Narrative
HISTORY OF FLIGHT
On September 10, 2014, at 1326 central daylight time, a Smith 601P, N711YM, impacted terrain «-mile north of the Austin-Bergstrom International Airport
(AUS), Austin, Texas. The pilot, the sole occupant on board, was fatally injured. The airplane was destroyed. 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 (VMC) prevailed at the time of the
accident, and no flight plan had been filed. The local flight originated from Dallas Executive Airport (RBD), Dallas, Texas, at 1226, and was en route to AUS.
At 1314, when the airplane was just east of the Georgetown Airport (GTU), Georgetown, Texas, the pilot asked for visual flight rules (VFR) flight following
services from AUS approach control. Radar contact was established and the pilot was given the AUS weather and was vectored towards runway 17L. Mode C
transponder returns indicated the airplane was at an altitude of 6,500 feet. At 1326:29, the pilot was told to contact the control tower. At that time, radar
indicated the airplane was just short of runway 17 and travelling at a ground speed of 88 knots. [The airplane's flaps down stall speed is 77 knots indicated
airspeed (KIAS), and its flaps up stall speed is 84 KIAS.] The pilot never contacted the tower. At 1341, the tower controller said she did not have radio contact
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with the airplane but could see smoke north of the airport. Units from the Austin Fire Department, who had responded to earlier reports of a ground cover fire,
discovered the wreckage.
The Austin Police Department interviewed six witnesses. The consensus of these interviews was that they saw a slow-flying airplane at low altitude, headed in
the direction of the airport. The left engine was at a low rpm and "sputtering, knocking," or making "banging" sounds and trailing black smoke. One witness said
that as the airplane passed over his location, he saw the tail "kick" horizontally to the right and the airplane banked slightly to the left. A review of radio
communications revealed the pilot never reported an inoperative engine or declared an emergency.
CREW INFORMATION
The 55-year-old pilot held a private pilot certificate with airplane single and multi-engine land ratings. He was not instrument rated. His third class airman
medical certificate, dated March 11, 2014, contained the restriction, "Must wear corrective lenses." When the pilot applied for this medical certificate, he
estimated his total flight time to be 525 hours. It was calculated that the pilot had accrued 36.8 hours in N711YM. The pilot's logbook was never located.
N711YM (serial number 61P-0215-023), a model 601P, was manufactured by the Ted Smith Aircraft Company, Santa Maria, California, in 1975. On October
30, 1990, the airplane was modified as a Machen Superstar I (700 Aerostar). This entailed the installation of two Lycoming IO-540-S1A5MM intercooled
engines [serial number L-13174-48A, (left); L-13175-48A (right)], each rated at 350 horsepower, driving two Hartzell 3-blade, all-metal, constant speed, full
feathering propellers (model number HC-C3YR-2, serial number CK4002A, left; CK4001A, right).
According to the previous owner, he and several mechanics spent considerable time maintaining the airplane in pristine condition. But during the 2011
economic downturn, the airplane was taken out of service and sat dormant on an open ramp at Patterson (PTN), Louisiana, for over 2 years. The owner had a
cover made to protect the airplane from the elements. The engines were started occasionally. In 2013, he advertised the airplane for sale in Trade-a-Plane.
Only a few inquiries were made, indicative of a "very soft" market for twin-engine airplanes. On June 7, 2013, a prospective buyer's mechanic made a
pre-purchase inspection of the airplane. The mechanic told his client that some of the engine cowling fasteners were rusty; others were broken. When he
removed the lower spark plugs, rusty water poured out. The mechanic terminated his inspection and told his client that the airplane was unairworthy, citing
Louisiana's humid environment conducive to metal corrosion.
In October 2013, the pilot approached the owner and offered $47,500, the approximate salvage value, for N711YM. The sale was consummated on December
26, 2013, and a bill of sale was negotiated. The pilot told the seller that he and his mechanic would fly the plane to Lancaster, Texas, on a ferry permit. The
seller described the pilot as "a very unusual person in a sense he would not listen to advice." The seller kept reminding the pilot that there were items that
needed to be inspected before he could safely fly the airplane. Since it had sat dormant for four years, the seller suggested that the pilot sump all the fuel
tanks, which he finally did after much cajoling. He also tested all the spark plugs and verified each plug was firing properly. He then boarded the airplane and
took off. The seller watched as the pilot "yanked" the airplane off the runway. He said the engines were not developing full power and were backfiring. The
Federal Aviation Administration (FAA) could find no record of a ferry permit being issued for this flight.
On February 6, 2014, the pilot flew the airplane to Mena, Arkansas, where it was stripped, primed, and repainted. The pilot departed Mena on March 24, 2014.
On both flights to and from Mena, there were no records of an annual inspection being made or a ferry permit being issued. On May 13, 2014, the altimeter,
transponder, and altitude reporting system were inspected and found to comply with FAR 91.411 and 91.413 up to an altitude of 25,000 feet.
A review of the maintenance records revealed an annual inspection was accomplished on June 3, 2010, at a total airframe time of 3,402.2 hours. The Hobbs
meter read 1,373.3 hours. On June 10, 2014, four years and 36.0 flight hours later, another annual inspection was performed at a total airframe time of 3,438.2
hours. The Hobbs meter read 1,409.3 hours. At the time of the accident, the Hobbs meter read 1410.2, a difference of 0.8 hours. At the time of the last annual
inspection, both engines received 100-hour inspections. Time elapsed since the last major overhaul of the left engine was 1,048.4 hours. Time elapsed since
the last major overhaul on the right engine was 178.6 hours. The previous 100-hour inspections were performed on June 3, 2010, at a Hobbs meter time of
1,373.3 hours. The left engine received a major overhaul on November 16, 1992, at a Hobbs meter time of 360.9 hours. The right engine received a major
overhaul on January 8, 2008, at a Hobbs meter time of 1,230.7 hours. Both propellers received 100-hour inspections on June 3, 2010, at a Hobbs meter time of
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1,409.3 hours.
On July 29, 2014, eight months after purchasing the airplane, the pilot filed for a new registration and it was issued on August 18, 2014.
According to a spokesperson for Jet Center of Dallas, between April 19 and April 30, the pilot based his airplane at RBD, and started leasing community hangar
space on May 1, 2014. During this time frame, the airplane was parked in the back of the hangar and did not fly. The first time the pilot flew the airplane was on
September 10, 2014, the day of the accident, and the only time he ever purchased fuel was on September 9, 2014, the day before the accident. He had
planned to fly on that day but had to cancel due to a dead battery.
The following weather observation was recorded at 1403 by the AUS Automated Weather Observing System (AWOS):
Wind, 210 degrees at 9 knots, gusting to 17 knots; visibility, 10 miles; sky condition, 5,000 feet, scattered; temperature, 36; dew point, 21; altimeter, 29.83
inches of mercury.
AERODROME INFORMATION
AUS is located 5 miles southeast of the City of Austin, and is situated at an elevation of 542 feet above mean sea level. Runway 17L-35R was 9,000 feet long
and 150 feet wide. It was constructed of concrete and grooved.
The physical address of the accident site was 2400 Cardinal Loop, Travis County, City of Austin. The investigation commenced September 11 and concluded
on September 12, 2014. The Austin Police Department's Vehicular Homicide Division assisted in the on-scene examination with the use of their Leica Total
Station.
The investigation disclosed the airplane initially struck a large tree as evidenced by numerous freshly shopped branches lying on the ground around the tree's
drip line. Wreckage was strewn for approximately 1,300 feet on a magnetic heading of 170 degrees. Approximately 450 feet beyond the first tree strike, a
second tree was struck with branches lying on the ground around its drip line. About 300 feet to the right of this tree, or about 800 feet from the initial tree strike,
was another large tree. Both wings had been sheared off and pieces of the right wing and propeller were scattered around its base.
About 300 feet to the left and back on the debris centerline were pieces of the wing spar. About 30 feet to the right on open flat ground was the inverted and
intact right propeller assembly embedded in the ground. About 30 feet beyond was a tree line was a line of trees, and the inverted cabin and cockpit were
suspended in these trees. The left engine and propeller remained attached to the wing stub, and the stub remained attached to the airplane. The separated
right engine was located in the gully behind the airplane.
Examination of the cockpit disclosed the altimeter was set to 29.86 inches of mercury. Both throttle, propeller, and mixture controls were full forward. The left
tachometer indicated 95 rpm and the right tachometer indicated 2,550 rpm. The flap and landing gear controls were up, and the Hobbs meter indicated 1,410.2
hours.
According to the autopsy report, the cause of death was "blunt force injuries." The report noted the pilot had focally severe coronary artery atherosclerosis, an
enlarged (550 grams) heart, and "remote" myocardial infarction. A review of his FAA medical examinations revealed the pilot had never reported any of these
medical issues. His blood pressure was deemed normal on his last FAA medical examination.
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According to the toxicology report, the only drugs detected in the pilot were acetaminophen, dextromethorphan, and dextrorphan. Acetaminophen (12 ug/ml,
ug/g) was detected in the urine. Dextromethorphan was also detected in the urine but not in femoral blood. According to FAA's drug database, acetaminophen
(Tylenolr) is used for the relief of fever, aches and pains. Dextromethorphan (Vicksr DayQuilr & NyQuilr) is a cough suppressant. Dextrorphan is the metabolite.
TESTS AND RESEARCH
On November 13-14, 2014, the engines were disassembled and examined at Air Salvage of Dallas, Lancaster, Texas, under the auspices of the National
Transportation Safety Board. The right engine revealed no anomalies that would have precluded the engine from developing power. Signatures on the right
propeller blades were consistent with power production and rotation on impact.
The left propeller was examined and found to be in the feathered position. The left engine spark plugs were removed and found to be heavily carbonized and
black, consistent with a rich fuel-air mixture. Further examination revealed the rubber boot that connected the intercooler to the fuel injector servo had become
dislodged and had been partially sucked in towards the servo. The clamp used to secure the hose was loose but remained around the servo. The safety wire
on the clamp was in place and the clamp was not damaged. The exhaust tubing also exhibited dark sooting.
At the time of the accident, the airplane was carrying only one occupant, no cargo, and less than full fuel. The blue line on the airspeed indicator that depicts
the best single-engine rate-of-climb airspeed was 118 knots indicated airspeed (KIAS).
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General Aviation Reports

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