National Transportation Safety Board

Transcription

National Transportation Safety Board - Aircraft Accident/Incident Database
Accident Rpt# ERA15CA176
04/03/2015 2015 CDT Regis# N9172Q
Acft Mk/Mdl BEECH V35B-B
Acft SN D-9250
Wetumpka, AL
Acft Dmg:
Fatal
Opr Name:
Printed: April 08, 2015
Page 1
0
Rpt Status: Prelim
Ser Inj
Opr dba:
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
0
Prob Caus: Pending
Flt Conducted Under: FAR 091
Aircraft Fire:
Copyright 1999, 2015, Air Data Research
All Rights Reserved
01/07/2015 945 EST
Acft Mk/Mdl CESSNA A185E
Opr Name: MARK ALLEN BANCROFT
Page 2
Regis# N70037
Lewiston, ME
Acft SN 18501905
Acft Dmg: SUBSTANTIAL
Rpt Status: Prelim
Acft TT
Fatal
5496
0
Apt: Oxford County Rgnl 81B
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire: NONE
All Rights Reserved
Accident Rpt# ANC14CA091
Acft Mk/Mdl PIPER J3C 65-65
09/28/2014 1450 AKD Regis# N7092H
Acft SN 20343
Ft. Yukon, AK
Acft Dmg:
Fatal
Opr Name: HARTE ROBERT B
Page 3
0
Rpt Status: Prelim
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire:
All Rights Reserved
09/28/2014 1152 EDT Regis# N3740A
Acft Mk/Mdl QUICKSILVER EIPPER ACFT INC GT
Acft SN GT 2801051
Lebanon, CT
Acft Dmg:
Fatal
Eng Mk/Mdl ROTAX 503
Opr Name:
Apt: Private Airstrip NONE
0
Rpt Status: Factual Prob Caus: Pending
Ser Inj
1
Opr dba:
Aircraft Fire:
AW Cert: UNK
Events
1. Initial climb - Controlled flight into terr/obj (CFIT)
Narrative
On September 28, 2014, at 1152 eastern daylight time, a Quicksilver Eipper GT 400, N3740A, was substantially damaged when it impacted trees while taking
off from a private airstrip in Lebanon, Connecticut. The non-certificated pilot was seriously injured. Visual meteorological conditions prevailed, and no flight plan
had been filed for the flight to Richmond Airport (08R), West Kingston, Rhode Island, under the provisions of 14 Code of Federal Regulations Part 91.
According to a witness, she was sitting in her living room when she heard what sounded like an airplane taking off from the airstrip located beyond the trees in
her back yard. It sounded very loud and low, so she ran to a window at the back of her house to see if it would clear the trees when she heard it hit the trees
and then crash. She heard the engine still running for a few minutes after the crash and then it stopped.
The pilot was interviewed by a Federal Aviation Administration (FAA) inspector while recovering in the hospital. According to the inspector, the pilot had flown
the airplane from his home airport [08R] to the uncontrolled, private airstrip. It had been about 8 years since he had last flown there, and the pilot was unaware
that the airstrip had been shortened by about 200 feet. The pilot did not speak to anyone and stayed there about an hour. When he decided to depart, he
configured the airplane with 10-degrees flaps, and departed to the [north]west. In an attempt to clear trees beyond the end of the runway, he pulled back on the
control stick and stalled the airplane into those trees.
In further correspondence with the NTSB, the pilot stated that he only used about half of the runway to take off. About 8 to 10 feet in the air, the pilot thought
the airplane would clear trees at the end of the runway, and he continued the climb. The nose landing gear cleared the trees, but the main landing gear caught
the top of a tree. The airplane then turned to the right, stalled, and descended through the trees to the ground.
Winds, recorded at a nearby airport at the time of the accident, were from 340 degrees true at 8, gusting 18 knots. Estimated dimensions of the airstrip from a
Google Earth view were about 1,050 feet by 40 feet, oriented 290/110 degrees true.
The airplane was originally operated under Federal Air Regulations Part 103 for ultralight aircraft. The airplane was registered in 2007, but that registration
expired in 2012. The pilot did not possess a pilot certificate, but indicated that he had flown an estimated 2,500 hours in ultralights with about 500 hours in
make and model.
The pilot did not report any preexisting mechanical anomalies that would have precluded normal airplane operation.
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Accident Rpt# CEN15LA183
03/29/2015 1600 CDT Regis# N80462
Acft Mk/Mdl BEECH 35
Acft SN D-62
Eng Mk/Mdl CONTINENTAL E-228-8
Opr Name: ROBERT L GENTRY
Gordonville, TX
Apt: Cedar Mills 3T0
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
2
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: STN
Events
1. Initial climb - Loss of engine power (total)
Narrative
On March 29, 2015, about 1600 central daylight time, a Beech 35, single-engine airplane, N80462, was substantially damaged after impacting terrain during
initial climb at Cedar Mills Airport (3T0), Gordonville, Texas. The pilot and one passenger were seriously injured, and two passengers sustained minor injuries.
The airplane was registered to and operated by a private individual. Day visual meteorological conditions (VMC) prevailed at the time of the accident and a
flight plan had not been filed for the 14 Code of Federal Regulations Part 91 personal flight which was destined for Tyler Pounds Regional Airport (TYR), Tyler,
Texas.
The pilot reported that during his soft field takeoff from the turf runway the airplane had lifted off at an indicated airspeed of 80 mph. As the airplane neared the
departure end of the runway the pilot noticed the airplane was not climbing as expected, the indicated airspeed seemed unreliable, and the controls felt mushy
and near stall speed. The airplane then impacted trees and the roof of an unoccupied home. The engine separated and fell inside the home which resulted in a
structure fire that substantially damaged the home. The airplane impacted terrain about 50 feet from the burning home and came to rest upright after impacting
two nearly full propane storage tanks. There was no release of propane and there was no postimpact fire at the location of the main wreckage. Several persons
at another nearby home witness the impact and responded immediately to assist the four occupants to exit the wreckage.
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Accident Rpt# ERA14LA324
06/26/2014 1645 CDT Regis# N9411Y
Gulf Shores, AL
Apt: Jack Edwards JKA
Acft Mk/Mdl BEECH 95 55
Acft SN TC-23
Eng Mk/Mdl CONT MOTOR I0-470 SERIES
Acft TT
Fatal
Opr Name: TACKETT JOHN Z
Opr dba:
4526
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Events
1. Landing-flare/touchdown - Abnormal runway contact
Narrative
On June 26, 2014, about 1645 central daylight time, a Beech BE-95, N9411Y, was substantially damaged during a hard landing at Jack Edwards Airport (JKA),
Gulf Shores, Alabama. The private pilot and a passenger were not injured. Visual meteorological conditions prevailed, and no flight plan was filed for the local
personal flight, which was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.
In a telephone interview, the pilot stated that there were no problems with the performance and handling of the airplane throughout the flight. He said that after
the airplane had touched down for the second time, and had slowed to approximately 30 knots during the landing roll, he observed a "shimmy" coming from the
nose area of the airplane. The nose landing gear then collapsed and the airplane slid on its nose until it stopped partially off to the side of the runway.
A witness located at the airport's fixed base operator (FBO) provided a written statement. He said the airplane touched down on all three landing gear
simultaneously, bounced, then landed hard on the nose landing gear, collapsing it. The airplane then skidded approximately 400 feet before it exited the side of
the runway.
Another witness stated the speed of the airplane was "excessive" and that it landed in a flat, "neutral" attitude, and bounced back into the air. At that point, the
witness lost sight of the airplane and did not see it touch down the second time.
The pilot held a private pilot certificate with ratings for airplane multiengine and single engine land. His most recent FAA third class medical certificate was
issued on June 13, 2014. He reported 4,000 total hours of flight experience, of which 500 hours were in the accident airplane make and model.
At 1655, the weather conditions reported at JKA included scattered clouds at 3,200 feet, visibility 10 miles, temperature 30 degrees C, dewpoint 23 degrees C,
and an altimeter setting of 30.02 inches of mercury. The wind was from 230 degrees at 3 knots.
The wreckage was recovered from the accident site and moved to the FBO. Examination of photographs revealed a separated nose landing gear, cut and torn
front tire, crushed nose cone, and substantial damage to the fuselage and cabin areas.
Examination of the wreckage by an FAA inspector revealed no preimpact mechanical anomalies. He stated that his review of the airplane revealed damage due
to overstress that was consistent with a hard landing.
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Accident Rpt# GAA15LA022
03/17/2015 1103 EDT Regis# N900TM
Acft Mk/Mdl BEECH A36-UNDESIGNAT
Opr Name: JOHNATHAN REPP
Acft SN E-1302
New Market, IN
Apt: N/a
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
0
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: STN
Events
1. Enroute - Fuel exhaustion
Narrative
On March 17, 2015 about 1100 eastern daylight time, a Beechcraft BE36A, N900TM, had a loss of engine power due to fuel exhaustion during cruise flight and
landed on an open field two miles southwest of New Market, Indiana. The pilot and sole passenger were not injured, and the airplane sustained substantial
damage. The airplane was registered to Red Top Aviation, Incorporated, Martinsville, Indiana, and operated by the pilot as a day, visual flight rules ferry flight
under 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed at the time of the accident and no flight plan was filed. The flight
originated from the Columbus Municipal Airport (BAK), Columbus, Indiana and was destined for Crawfordsville Municipal Airport (CFJ), Crawfordsville, Indiana.
According to the pilot, after departing BAK, he observed that the right tip tank seemed very slow to transfer fuel. The airplane experienced fuel exhaustion
en-route and he maneuvered the airplane for landing in an open field near New Market, Indiana. The airplane sustained substantial damage to the right rear
wing spar.
The pilot stated there was a known issue with the tip tanks transfer of fuel.
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Accident Rpt# WPR15LA132
03/22/2015 1150 MST Regis# N7628R
Acft Mk/Mdl BEECH B23
Acft SN M-1249
Eng Mk/Mdl LYCOMING O&VO-360 SER
Opr Name: WILSON RODNEY C
Flagstaff, AZ
Apt: Flagstaff Pulliam FLG
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
0
Prob Caus: Pending
Aircraft Fire: NONE
Events
1. Landing-landing roll - Loss of control on ground
Narrative
On March 22, 2015, about 1150 mountain standard time, a Beech B23, N7628R, veered off of runway 21 during the landing rollout at the Flagstaff Pulliam
Airport (FLG), Flagstaff, Arizona. The private pilot/owner operated the airplane under the provisions of 14 Code of Federal Regulations Part 91 as a local area
personal flight. The pilot and passenger were not injured. The airplane sustained substantial damage. Visual meteorological conditions prevailed for the local
area flight and no flight plan had been filed. The flight departed FLG about 1050.
According to the pilot, during the landing rollout, as the airplane began to veer to the left of the runway, he applied right rudder and aileron. However, the
airplane continued to veer to the left, exited the runway, and struck a precision approach path indicator (PAPI) light. The pilot believed that there may have
been a problem with the rudder control bungees or springs.
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Acft Mk/Mdl BEECH H35
Opr Name: SKYLER AVIATION
03/30/2015 1130 MST Regis# N112F
Acft SN D-5200
Tucson, AZ
Apt: Tucson Intl TUS
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
0
Prob Caus: Pending
Aircraft Fire: NONE
Events
1. Takeoff - Loss of lift
Narrative
On March 30, 2015, about 1130 mountain standard time, a Beech H35, N112F, was substantially damaged during a forced landing at Tucson International
Airport, Tucson, Arizona. The private pilot, the sole occupant, was not injured. The airplane was registered to Skyler Aviation, and operated by the pilot under
the provisions of 14 Code of Federal Regulations (CFR) Part 91 as a personal flight. Visual meteorological conditions prevailed, and no flight plan had been
filed. The flight originated from Tucson International Airport, Tucson, about 1130.
The pilot reported that during the takeoff, the airplane was not developing adequate power. At about 40 feet above ground level, the airplane stopped climbing,
and the pilot initiated a forced landing to a nearby field. The airplane impacted terrain and nosed over, which resulted in substantial damage to the firewall.
The airplane has been recovered to a secure location for further examination.
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Accident Rpt# GAA15CA031
Acft Mk/Mdl CESSNA 140-G
Opr Name:
Page 10
03/16/2015 1145 EDT Regis# N2026V
Acft SN 14297
Easton, MD
Apt: Easton/newnam Field ESN
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire: NONE
All Rights Reserved
Accident Rpt# CEN15FA189
04/02/2015 600 CDT
Acft Mk/Mdl CESSNA 152
Regis# N65463
Batesville, AR
Acft SN 15281566
Acft Dmg: DESTROYED
Fatal
Eng Mk/Mdl LYCOMING 0-235 SERIES
Opr Name: WELCH TIMOTHY
1
Apt: N/a
Ser Inj
Opr dba:
Rpt Status: Prelim
0
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: STN
Events
1. Enroute - Unknown or undetermined
Narrative
On April 2, 2015, about 0600 central daylight time, a Cessna 152 airplane, N65463, collided with terrain near Batesville, Arkansas. The student pilot, the sole
occupant, 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 an instructional flight. Night, instrument meteorological conditions prevailed in the vicinity of the accident site. The flight
operated without a flight plan and departed the Salem Airport (7M9), Salem, Arkansas, at an undetermined time.
According to preliminary information, the pilot and another individual departed Carlisle Municipal Airport (4M3), Carlisle, Arkansas, about 0200. The pilot
intended to fly to 7M9. The pilot's activities until the time of the accident have not been determined.
About 0600, a resident called the Independence County Sheriff to report a possible airplane crash. The resident heard an airplane's engine rev up and then
heard what she thought was a crash. When the deputies arrived to her resident and began investigating the area, they reported heavy patchy fog. The
airplane's wreckage was located on April 3, 2015, in a wooded area of Brock Mountain.
At 0555, an automated weather reporting facility located at the Batesville Regional Airport (BVX), Batesville, Arkansas, about 6.5 nautical miles northeast of the
accident site, reported wind from 190ø at 6 knots, visibility 10 miles, few clouds at 1,000 feet, a broken layer at 1,900 feet, and an overcast ceiling 3,200 feet,
temperature 18ø Celsius (C), dew point 16ø C, and a barometric pressure of 29.87 inches of mercury.
At 0535, an automated weather reporting facility located at the Clinton Municipal Airport (CCA), Clinton, Arkansas, located 34 nautical miles west of the
accident site, reported a calm wind, visibility 5 miles, mist, an overcast ceiling at 700 feet, temperature 16øC, dew point 16ø C, and a barometric pressure of
29.88 inches of mercury.
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Accident Rpt# WPR14CA379
09/01/2014 1400 PDT Regis# N67367
Santa Rosa, CA
Apt: Santa Rosa STS
Acft SN 15281784
Eng Mk/Mdl LYCOMING O-235-L2C
Acft TT
Fatal
Opr Name: NORTH COAST AIR INC
Opr dba:
15952
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Summary
The student pilot completed three takeoffs and landing with the certified flight instructor (CFI) on board, then took off for his first solo flight in the pattern. During
the first landing, the airplane bounced twice and on the third touchdown, the nose gear collapsed and the airplane slid to a stop. The student pilot was not
injured, but the airplane sustained substantial damage to the firewall. There were no reports of preimpact mechanical malfunctions or failures with the airplane
that would have precluded normal operation.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The student pilot's inadequate
flare resulted in a hard landing.
Events
2. Landing-flare/touchdown - Hard landing
Findings - Cause/Factor
1. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Landing flare-Incorrect use/operation - C
2. Personnel issues-Action/decision-Action-Incorrect action performance-Student/instructed pilot - C
Narrative
The student pilot completed three takeoffs and landing with the certified flight instructor (CFI) on board, then took off for his first solo flight in the pattern. During
the first landing, the airplane bounced twice and on the third touchdown, the nose gear collapsed and the airplane slid to a stop. The student pilot was not
injured, but the airplane sustained substantial damage to the firewall. There were no reports of preimpact mechanical malfunctions or failures with the airplane
that would have precluded normal operation.
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04/04/2013 930 MST
Regis# N2166K
Phoenix, AZ
Acft Mk/Mdl CESSNA 172-S
Acft SN 172S9792
Eng Mk/Mdl LYCOMING IO-360-L2A
Acft TT
Fatal
Opr Name: WESTWIND SCHOOL OF AERONAUTICS
Opr dba:
3258
0
Apt: Deer Valley DVT
Ser Inj
0
Aircraft Fire: NONE
Events
1. Takeoff - Loss of control on ground
Narrative
HISTORY OF FLIGHT
On April 4, 2013, about 0930 mountain standard time, a Cessna 172S, N2166K, was substantially damaged when it impacted airport terrain during an
attempted takeoff from Deer Valley Airport (DVT), Phoenix, Arizona. The certified flight instructor (CFI), the student pilot, and the passenger-observer were
uninjured. The instructional flight was operated under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed.
According to information provided by the CFI and the responding inspector from the Federal Aviation Administration (FAA) Flight Standards District Office, the
purpose of the flight was to practice takeoffs and landings. The student pilot was seated in the left seat, and the CFI was in the right seat. During the takeoff roll
on runway 7R, the student pilot was handling the controls. After power application, he initially overcorrected with right rudder, and the airplane began to veer
right. The CFI then verbally instructed the student to correct back to the left, which he did. However, again the student pilot overcorrected, and the airplane
veered towards the left side of the runway, while continuing to accelerate. About the time that the airplane crossed the runway centerline from right to left, the
CFI took physical control of the airplane, and as it approached the left runway edge, the CFI attempted to lift off. After liftoff, the nose "dropped," the airplane
banked to the right, and struck the runway. About the same time the CFI reduced power on the engine. The airplane came to rest inverted. All occupants
evacuated the airplane, and there was no fire, or any indications of a fuel spill.
PERSONNEL INFORMATION
General
According to information provided by Westwind School of Aeronautics (WSA), the CFI, the student pilot, the passenger, and the airplane were all associated
with the flight training program at WSA, which was based at DVT.
Student Pilot
Examination of the student pilot's logbook indicated that he had a total flight experience of about 4 hours, all of which was in the accident airplane make and
model. The logbook indicated that his first instructional flight was conducted 6 days before the accident flight, and that the accident flight was his fourth flight.
Certificated Flight Instructor
FAA records indicated that the CFI obtained his flight instructor certificate in February 2013, and obtained his commercial certificate in August 2012. Both were
valid for airplane single engine only. His most recent FAA first-class medical certificate was issued in December 2011.
According to information provided by the flight school, the CFI had a total flight experience of about 308 hours, all of which was in single-engine airplanes. He
had performed as a flight instructor for a total of about 57 hours, including 39 hours in the accident airplane make and model.
AIRCRAFT INFORMATION
FAA records indicated that the airplane was manufactured in 2005, and was registered to a corporation based in Phoenix. It was equipped with a Lycoming
IO-360 series engine. According to information provided by the flight school, the airplane had accumulated a total time in service of about 3,271 hours at the
time of the accident. The most recent inspection was accomplished on March 15, 2013, and the airplane had been operated about 13 hours since then.
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METEOROLOGICAL INFORMATION
The DVT 0953 automated weather observation included wind from 230 degrees at 3 knots, visibility 10 miles, clear skies, temperature 24 degrees C, dew point
1 degree C, and an altimeter setting of 30.05 inches of mercury.
AIRPORT INFORMATION
The elevation of DVT was 1,478 feet above mean sea level (msl), and runway 7R dimensions were reported as 8,196 feet by 100 feet. Coarse gravel was used
as ground cover in many non-paved areas. The airport was equipped with an air traffic control tower, which was operational at the time of the accident.
WRECKAGE AND IMPACT INFORMATION
The airplane came to rest adjacent to the south (right) side of runway 7R, about 1,450 feet from where the takeoff roll began. Site information provided by the
responding FAA inspector indicated that the ground scars extended about 300 feet. The airplane veered off the left side of 7R just prior to taxiway B3, and then
traversed off the right side of the runway about 150 feet beyond the left-excursion. Paint transfer marks and airplane damage were consistent with the airplane
first striking the right wing and tailplane on the runway. Propeller slash marks were evident in the runway pavement.
The lower section of the nose gear was fracture-separated from the strut. The nose was crushed up and aft, and the aft fuselage was crumpled slightly. Both
wings, as well as the horizontal and vertical stabilizers, sustained crush damage and denting. The propeller tips exhibited significant curling.
Examination of the airplane did not detect any pre-impact anomalies with any of the flight control systems, and the pilots did not report any mechanical
problems or deficiencies with the airplane.
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01/23/2015 1240 EST Regis# N35560
Nashua, NH
Apt: Boire Field ASH
Acft Mk/Mdl CESSNA 172I
Acft SN 17256835
Acft TT
Fatal
Opr Name: RONALD L. EMOND
Opr dba: AIR DIRECT AIRWAYS FLIGHT ACADEMY
8277
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Summary
According to the flight school operator, the solo, student pilot was directed by air traffic control to taxi via taxiway Charlie and the inner ramp to the parking
area. A fence construction company truck was parked on the edge of the active taxiway while the personnel inside the truck were having lunch. As the pilot
taxied the airplane past the truck, while on the yellow taxi line, the left wing struck the upper cab of the truck. The pilot reported that she did not see the truck
prior to the collision and it was parked in the shadow of a building. A Federal Aviation Administration inspector reported that the collision resulted in substantial
damage to the left wing. The student pilot did not report any mechanical problems with the airplane at the time of the accident. FAA Advisory Circular 91-73B,
which provides guidance on single pilot taxi operations, states, "Situational Awareness (SA). When conducting taxi operations, pilots need to be aware of their
proximity to other aircraft and vehicles moving on the airport."
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The student pilot's lack of
vigilance during taxi, which resulted in a collision with a parked truck. A factor in the accident was the truck operator's decision to park on the edge of an active
taxiway.
Events
1. Taxi - Ground collision
1. Personnel issues-Psychological-Attention/monitoring-Task monitoring/vigilance-Student/instructed pilot - C
2. Environmental issues-Physical environment-Object/animal/substance-Ground vehicle-Effect on operation
3. Personnel issues-Action/decision-Info processing/decision-Decision making/judgment-Other/unknown - F
Narrative
According to the flight school operator, the solo, student pilot was directed by air traffic control to taxi via taxiway Charlie and the inner ramp to the parking
area. A fence construction company truck was parked on the edge of the active taxiway while the personnel inside the truck were having lunch. As the pilot
taxied the airplane past the truck, while on the yellow taxi line, the left wing struck the upper cab of the truck. The pilot reported that she did not see the truck
prior to the collision and it was parked in the shadow of a building. A Federal Aviation Administration inspector reported that the collision resulted in substantial
damage to the left wing. The student pilot did not report any mechanical problems with the airplane at the time of the accident. FAA Advisory Circular 91-73B,
which provides guidance on single pilot taxi operations, states, "Situational Awareness (SA). When conducting taxi operations, pilots need to be aware of their
proximity to other aircraft and vehicles moving on the airport."
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06/12/2013 930 CDT
Regis# N7045G
Newton, MS
Acft Mk/Mdl CESSNA 172K
Acft SN 17258745
Eng Mk/Mdl LYCOMING O-360-A4M
Acft TT
Fatal
Opr Name: NEWTON FLYING CLUB INC
Opr dba:
10891
1
Apt: James H. Easom Field M23
Ser Inj
1
Aircraft Fire: NONE
Events
1. Approach-VFR pattern final - Controlled flight into terr/obj (CFIT)
Narrative
HISTORY OF FLIGHT
On June 12, 2013, about 0930 central daylight time, a Cessna 172K, N7045G, was substantially damaged when it impacted terrain after striking an electrical
transmission power line during approach, at James H. Easom Field Airport (M23), Newton, Mississippi. The student pilot was fatally injured, and the flight
instructor was seriously injured. Visual meteorological conditions prevailed, and no flight plan was filed for the local instructional flight, which was operated
under the provisions of Title14 Code of Federal Regulations (CFR) Part 91.
According to the flight instructor, on the day of the accident, he met with the student pilot, then after briefing him, the student pilot preflighted the airplane. After
starting the engine, they taxied out and then took off from runway 31. After takeoff, they flew in a southwesterly direction and climbed to an altitude of 2,000
feet above mean sea level (msl). After a little while, they returned to the airport for landing. After arriving in the vicinity of the airport, the student entered a left
downwind for runway 31 at 1,200 feet msl. The flight instructor then asked the student to turn on to the base leg of the traffic pattern but "he was slow to
respond," and they were too fast, which extended the downwind leg farther out than normal. The flight instructor then noticed that the student pilot had not
extended the wing flaps to the 10 degree position. A little while later, the student pilot extended the wing flaps to 10 degrees, and started to slow the airplane.
The flight instructor then asked the student to turn final, and because of the extended downwind which had placed them farther out than normal, to stop
descending and add power. The student pilot then arrested the descent, but failed to add power and climb to a normal pattern altitude. The flight instructor then
asked once more for the student pilot to add power, however the student pilot did not respond by adding power and initiating a climb or by asking the flight
instructor for clarification.
The flight instructor stated that he was distracted by the airspeed and the student pilot's lack of response and did not see the powerlines on final approach to
runway 31. Then, when he finally did see the powerlines, he took control of the airplane, added full power, and added maximum up elevator. The airplane then
cleared all of the powerlines except one, which ran along the top of the poles above the larger lines which was a different color and hard to see. The nosewheel
landing gear then came into contact with the wire; the airplane nosed over, fell, and then impacted terrain.
The flight instructor advised that as part of the flight lesson, he had wanted the student pilot to get comfortable with the airplane and that he had wanted him to
fly as much as possible. The flight instructor further advised that he must have flown over the power lines at M23 at least a thousand times, and that he was
trying to teach but, had gotten distracted with the student pilot's speed, and altitude, and had forgotten all about the power lines.
According to Federal Aviation Administration (FAA) and pilot records, the flight instructor held an airline transport pilot certificate with ratings for airplane
multi-engine land, commercial privileges for airplane single-engine land. He also held type ratings for the BE-300, CE-500, and EMB-500, and a flight instructor
certificate with a rating for airplane single-engine. His most recent FAA second-class medical certificate was issued on October 2, 2012. He reported 6,450 total
hours of flight experience, 500 of which, was in the accident airplane make and model.
According to FAA and pilot records, the student pilot was issued a student pilot certificate with third-class medical on November 8, 2012 with a limitation which
stated "Must use hearing amplification."
The student pilot had never soloed in any aircraft. He had accrued 20 hours of total flight experience, all of which was accrued while he was receiving flight
instruction in the accident airplane make and model.
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The accident aircraft was a strut braced high wing, four seat, airplane, of conventional metal construction. It was equipped with tricycle type landing gear, and
was powered by a 180 horsepower, normally aspirated, 4 cylinder, air cooled engine, driving a fixed pitch, two bladed, metal propeller.
According to FAA and airplane maintenance records, the airplane was manufactured in 1969. The airplane's most recent annual inspection was completed on
July 1, 2012. At the time of the inspection, the airplane had accrued 10,671.7 total hours of operation.
The reported weather at Key Field Airport (MEI), Meridian, Mississippi, located 20 nautical miles east of the accident site, at 0958, approximately 28 minutes
after the accident, included: winds 300 degrees at 7 knots, 10 miles visibility, sky clear, temperature 30 degrees C, dew point 23 degrees C, and an altimeter
setting of 30.10 inches of mercury.
AIRPORT INFORMATION
According to the airport facility directory, M23 was a public use, uncontrolled airport, owned by the town of Newton, Mississippi. At the time of the accident, it
averaged 25 aircraft operations per day, 62 percent of which were transient general aviation, 36 percent of which were local general aviation, and 3 percent of
which were military.
It had one runway oriented in a 13/31 configuration. The runway was asphalt, and in good condition. The total length was 3,800 feet long and 75 feet wide. The
runway gradient for runway 31 was 0.4 percent. It was marked with basic markings in good condition.
Obstacles in the form of 109 foot tall trees located 2,600 feet from the runway threshold and 300 feet left of the centerline existed off the approach end of
runway 31, which required a 22:1 slope to clear. A Pulsating Visual Approach Slope Indicator (PVASI) was located on the left side of the runway. The PVASI
when used would provide a 7.00 degree glide path for visual descent guidance during approach to assure obstacle clearance.
Examination of the wreckage revealed that the airplane had come to rest inverted next to an electrical transmission corridor right of way that crossed the final
approach path approximately 2,290 feet from the threshold of runway 31. Wire contact marks were observed on the nose landing gear tire, the nose landing
gear strut, the lower engine cowling, the engine mount structure, and the propeller. The wire marks were consistent with the airplane coming into contact while
in a left bank, first with the propeller, and then with the nose landing gear.
Airframe Examination
Examination of the airplane revealed that control continuity existed from the ailerons, elevator, and rudder, to the control wheels and rudder pedals, and from
the elevator trim tab, to the trim wheel.
The fuel tanks were empty, however evidence of fuel having been present existed in the form of fuel staining on the fuselage and fuel dripping from the
wreckage during the examination. The fuel strainer screen and fuel strainer bowl were clean, and the fuel selector handle had been moved to the "off" position
by first responders.
The airplane was equipped with seatbelts; however no shoulder harnesses were installed. The data tags on the seatbelts were worn and unreadable and the
left front seat's secondary seat stop reel belt end fitting was not attached to the cabin floor. The reel's cable was also separated from the cable end just below
the swaged end, and a rub mark was visible on the seat locking pin. The cable end mounting bracket was also mounted further forward on the seat frame than
normal resulting in the cable bending as it exited the sheathing and rubbing against the seat pin.
The master switch was on, the throttle was in the full throttle position, and the mixture was in the full rich position. The primer was in and locked, and the
carburetor heat was off. The flap selector handle had been separated from its mounting location and the magneto switch had been turned to the off position by
first responders.
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Engine Examination
Examination of the engine did not reveal any preimpact failures or malfunctions that would have precluded normal operation of the engine. Drive train continuity
was confirmed from the propeller flange to the back of the engine, thumb compression was present on all 4 cylinders, the top sparkplugs appeared to be
normal, and both magnetos had remained attached to the engine.
Transmission Line Examination
Examination of the electrical transmission lines revealed that they were not equipped with wire markers and that the "top wire" the airplane struck was the three
strand 5/16th inch diameter static wire located above the conductors (cables) which were strung between the 75 foot high transmission towers.
Further examination revealed that approximately 1,000 feet of the static wire and two insulator shoes required replacement due to the airplane's impact with the
static wire.
Review of the Airport Facility Directory revealed that the powerlines were not listed in the airport information for M23 however; review of the Memphis Sectional
Aeronautical Chart revealed that they were depicted on the sectional aeronautical chart and were easily recognizable.
MEDICAL AND PATHOLOGICAL INFORMATION
An Autopsy was performed on the student pilot by the Mississippi State Medical Examiner's Office.
Cause of death was blunt force trauma.
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.
TESTS AND RESEARCH
Cockpit Noise
According to the FAA's Medical Facts for Pilots publication (AM-400-98/3), the sound intensity in the cockpit of an average single engine airplane is 70 to 90
Decibels and loud noise can interfere with or mask normal speech, making it difficult to understand.
Use of Hearing Aid
According to the FAA, the pilot was required to use hearing amplification while exercising the privileges of his student pilot certificate as he was unable to
demonstrate during the examination for his third-class medical that he had the ability to hear an average conversational voice in a quiet room, using both ears,
at a distance of 6 feet from the Examiner, with his back turned to the Examiner.
According to the pilot's wife, "he used to wear a hearing aid but no longer did."
According to the flight instructor, on the accident flight, neither he or the student pilot were wearing a headset, and when he told the student pilot to "Push the
power up," it seemed like the student pilot did not hear him, and he did not recall the student pilot wearing a hearing aid.
No hearing aid was recovered from the wreckage or accident site.
Survey of Airport and Accident Site
At the request of the NTSB, Mississippi Power Company, conducted a survey using Laser Illuminated Detection And Ranging equipment (LIDAR), and
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conventional survey means, to determine whether the electrical transmission lines which existed in the electrical transmission corridor right of way which
existed off the approach end of the runway, were an obstruction for aircraft landing on runway 31 at M23.
Review of the survey revealed that not only were the electrical transmission lines below the 7.00 degree glide path displayed by the PVASI, but they were
below the obstruction identification surfaces listed under Title 14 CFR Part 77, and in many areas were at or below the trees that were located on the approach
end of runway 31.
ADDITIONAL INFORMATION
In order to improve safety, Mississippi Power Company advised the NTSB on October 19, 2013 that they had installed Spherical Aviation Wire Markers to help
preclude wire strikes by aircraft that inadvertently descended below the obstruction identification area for runway 31 at M23.
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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
Summary
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.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: Pilot's inadequate control of the
airplane during the landing roll, which resulted in a runway excursion.
Events
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-Pilot - C
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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Accident Rpt# CEN15CA097
01/05/2015 1535 EST Regis# N6591H
Marquette, MI
Apt: Sawyer Intl SAW
Acft Mk/Mdl CESSNA 172M-M
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
Summary
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.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot did not maintain
directional control during takeoff on the snow and ice covered runway in gusting crosswind conditions.
Events
1. Takeoff - Loss of control on ground
1. Environmental issues-Conditions/weather/phenomena-Wind-Crosswind-Decision related to condition - C
3. Environmental issues-Physical environment-Runway/land/takeoff/taxi surface-Snow/slush/ice covered-Effect on equipment
4. Environmental issues-Conditions/weather/phenomena-Wind-Crosswind-Effect on operation
5. Environmental issues-Conditions/weather/phenomena-Wind-Gusts-Effect on operation
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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09/10/2014 2021 EDT Regis# N63835
Spruce Creek, FL
Apt: Spruce Creek 7FL6
Acft Mk/Mdl CESSNA 172P
Acft SN 17275487
Acft TT
Fatal
Opr Name: LIAO AVIATION INC.
Opr dba: LIAO AVIATION, INC.
8312
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Events
1. Approach-VFR pattern final - Fuel exhaustion
Narrative
On September 10, 2014, about 2021 eastern daylight time, a Cessna 172P, N63835, was substantially damaged when it collided with trees and terrain following
a total loss of engine power on approach to Spruce Creek Airport (7FL6), Spruce Creek, Florida. The flight instructor /owner and the commercial-rated pilot
receiving instruction sustained minor injuries. Night visual meteorological conditions prevailed, and a composite VFR/IFR flight plan was filed for the
instructional flight, which was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.
Both pilots were interviewed by telephone, and each provided a written statement. According to the instructor, the purpose of the flight was to log a number of
instrument approaches for the pilot receiving instruction in order to meet certificate requirements in his home country. The pilot receiving instruction stated he
did not have a checklist for the airplane, and relied on the instructor's "knowledge of the airplane" to complete the preflight inspection. He stated the fuel tanks
were "almost full" prior to the flight, and that the instructor told him the available fuel would provide 6 hours of fuel endurance.
The airplane departed 7FL6 at 1657 for West Palm Beach, Florida (PBI), and Vero Beach, Florida (VRB). The crew performed touch-and-go landings at PBI
and VRB before returning to the departure airport, and the airplane was on final approach for landing at 7FL6 when the engine stopped producing power. The
instructor said he attempted an engine restart and ensured that best glide speed was maintained before the airplane struck trees and the ground.
The pilot receiving instruction stated that the fuel selector was in the "Both" position throughout the flight. On final approach to 7FL6, he noticed that the fuel
selector had been switched to the "Right" tank position, and he moved the selector back to "Both." Shortly thereafter, the engine stopped producing power.
The instructor stated that on final approach the pilot inadvertently selected the "Off" position when he moved the selector from the "Right" tank position and the
engine quit. He attempted to restart the engine and helped the pilot maintain best glide speed until the airplane collided with the trees.
According to Federal Aviation Administration (FAA) air traffic control records, multiple one-leg flight plans were filed for the accident flight. The estimated fuel
endurance filed for the first leg, and each of the subsequent legs, was 3 hours and 20 minutes. While fuel was available at each of the airports where the
airplane performed approaches and touch-and-go landings, the airplane was not serviced with fuel at any point along the flight.
In the NTSB Form 6120.1 Pilot/Operator Aircraft Accident Report form, the instructor/owner/operator stated there were 30 gallons of fuel on board at departure.
The instructor held a flight instructor certificate with ratings for airplane single engine and instrument airplane. His most recent FAA first-class medical
certificate was issued on July 3, 2013, and he reported 250 hours of flight experience on that date. When interviewed, he reported about 314 total hours of flight
experience, of which 212 hours were in the accident airplane make and model.
The pilot receiving instruction held a commercial pilot certificate with ratings for airplane single engine land, multiengine land, and instrument airplane. His most
recent FAA first class medical certificate was issued July 15, 2011.
According to FAA records, the airplane was manufactured in 1981. Its most recent 100-hour inspection was completed December 11, 2013, at 8,312 total
aircraft hours.
According to the pilot's operating handbook, the airplane's fuel capacity was 43 gallons, of which 40 gallons were usable. The fuel consumption rate at 66
percent power given the conditions of the accident flight was 7.4 gallons per hour in cruise. The fuel required for the multiple full-power takeoffs and climbs
during the flight was not computed.
At 2053, the weather conditions reported at Daytona Beach, Florida (DAB), 6 miles west of the accident location, included few clouds at 2,400 feet, visibility 10
miles, temperature 27 degrees C, dew point 23 degrees C, and an altimeter setting of 30.03 inches of mercury. The wind was from 080 degrees at 6 knots.
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The wreckage was examined by an FAA inspector at the accident site, which revealed a separated right wing and damage to the cabin and empennage. Control
continuity was established to all flight control surfaces, and the examination revealed no preimpact mechanical anomalies. The left wing fuel tank was intact,
and contained no fuel. The right wing tank was intact, and contained about 3 gallons of fuel.
A test run of the engine was performed following the accident utilizing the fuel found in the right wing tank. The engine started immediately, accelerated
smoothly, and ran continuously with no anomalies observed.
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03/07/2015 1518 EST Regis# N144ME
Acft Mk/Mdl CESSNA 172S
Opr Name: AV-ED FLIGHT SCHOOL INC.
Page 24
Richmond, VA
Apt: Richmond International RIC
Acft SN 172S8428
Rpt Status: Prelim
Acft TT
Fatal
3838
0
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire: NONE
All Rights Reserved
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
Summary
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.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The student pilot's failure to
maintain airplane control during the initial climb, resulting in a runway excursion and substantial damage to the engine firewall. The student pilot's lack of overall
flying experience was a factor.
Events
1. Initial climb - Loss of control in flight
2. Landing - Runway excursion
1. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Lateral/bank control-Not attained/maintained - C
2. Personnel issues-Task performance-Use of equip/info-Aircraft control-Student/instructed pilot - C
3. Personnel issues-Experience/knowledge-Experience/qualifications-Total experience-Student/instructed pilot - F
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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03/28/2015 930 MST
Acft Mk/Mdl CESSNA 172S-S
Opr Name: H & H VERSATILE SERVICES INC
Page 26
Regis# N2168D
Vernal, UT
Acft SN 172S9649
Rpt Status: Prelim
Fatal
0
Apt: Vernal Rgnl VEL
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire: NONE
All Rights Reserved
01/10/2015 1018 PST Regis# N2229C
Jackson, CA
Apt: Westover Field Amador County JAQ
Acft SN 30529
Eng Mk/Mdl CONT MOTOR O-470 SERIES
Acft TT
Fatal
5205
0
Ser Inj
Opr Name: CORNELL DAVID A & HANSEN MICHAEL Opr dba:
C
0
Aircraft Fire: NONE
Events
Narrative
On January 10, 2015, at 1018 Pacific standard time, a Cessna 180, N2229C, veered off the runway surface and came to rest inverted while landing at
Westover Field Amador County Airport, Jackson, California. The private pilot, the sole occupant, was not injured. The airplane sustained substantial damage.
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. Visual
meteorological conditions prevailed, and no flight plan had been filed. The flight originated from Auburn Municipal Airport, Auburn, California, about 0900.
The pilot stated that he was conducting a personal cross-country flight. He performed several takeoffs and landings at different airports with no incidents before
continuing to Westover Field Amador County Airport.
As the airplane approached the airport, the pilot noted the wind was calm. He made a pass over the airport before he entered a left traffic pattern and landing to
runway 19. The pilot reported the touchdown was normal. Shortly thereafter, the airplane began to veer left. In response the pilot applied right rudder control,
right brake and right aileron, and added power to increase rudder authority. Despite his efforts to regain directional control, the airplane continued off the left
edge of the runway. The left main landing gear started to slide down an embankment that was adjacent to, and 6 feet lower, than the runway surface. The
propeller struck the ground and the airplane slid into the embankment. It subsequently nosed over and came to rest inverted. The airplane sustained substantial
damage to both wings and tail section. The pilot stated that after he exited the aircraft, he noted that the left wheel was locked, and the right wheel was
spinning.
A Federal Aviation Administration certified mechanic completed a post accident examination of the brake system. The examination revealed no evidence of
preimpact mechanical malfunctions or failures that would have precluded normal operation.
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08/10/2014 723 MDT
Regis# N7784A
Salmon, ID
Acft Mk/Mdl CESSNA 180A-A
Acft SN 32681
Eng Mk/Mdl CONTINENTAL O-470
Acft TT
Fatal
Opr Name: HAWKES DARIN M
Opr dba:
3126
0
Apt: Lemhi County SMN
Ser Inj
0
Aircraft Fire: NONE
Events
1. Initial climb - Loss of engine power (partial)
Narrative
On August 10, 2014, about 0723 mountain daylight time, a Cessna 180A, N7784A, sustained substantial damage during a forced landing following a loss of
engine power during takeoff initial climb from the Lemhi County Airport (SMN), Salmon, Idaho. The airplane was registered to and operated by the pilot under
the provisions of Title 14 Code of Federal Regulations Part 91. The private pilot and his three passengers were not injured. Visual meteorological conditions
prevailed, and no flight plan was filed for the personal flight. The cross-country flight was originating at the time of the accident with an intended destination of
Ogden, Utah.
In a written statement to the National Transportation Safety Board (NTSB) investigator-in-charge (IIC), the pilot reported that prior to takeoff he conducted an
engine run up, which included leaning the mixture for the high altitude airport, a magneto check, and cycling the propeller once. The pilot stated that during
takeoff from runway 35, he applied full power, and observed 24.1 inches of manifold pressure and 2,690 revolution per minute (rpm), with no abnormalities
noted. As the airplane ascended through about 300 feet above ground level, the pilot reduced the propeller setting to 2,400 rpm as part of his normal procedure.
Shortly thereafter, he noticed a difference in aircraft and engine performance, as if the engine was not producing thrust. The pilot verified the fuel selector,
throttle, mixture, and propeller settings, and initiated a forced landing to a nearby field. During the landing roll, the airplane struck a fence and the left main
landing gear separated from the airplane. Subsequently, the left wing struck the ground and the airplane came to rest upright.
Postaccident examination of the airplane by the pilot revealed that the left wing and aileron were structurally damaged. The wreckage was recovered to a
secure location for further examination.
Examination of the airplane by the NTSB IIC and a representative of Cessna Aircraft was conducted at the facilities of Aircraft Structural Repair, Stevensville,
Montana, on April 13, 2014. The examination revealed that the wings, horizontal stabilizer, and elevators had been removed to facilitate transport of the
wreckage. The cowling was removed and the engine was examined. The primer line from the "T" fitting to the number six cylinder was loose at the "T" fitting.
The top number 2, 3, 4, 5, and 6 spark plug harness leads were finger tight on the spark plugs. All additional fuel lines and fittings were found secure. Throttle,
mixture, propeller, and carburetor heat control continuity was established from the cockpit controls to the engine. The induction and exhaust system was intact.
The propeller, a McCauley 2A34C66-CMNO/S-90AT-4 two-bladed constant speed propeller, remained attached to the propeller flange. Propeller blade two was
found loose within the propeller hub.
In order to facilitate an engine run, the two-bladed propeller was removed and replaced with a serviceable three-bladed propeller. An alternate fuel source was
attached to the left wing fuel inlet port. The engine was primed and subsequently started. The engine was run uneventfully for less than 10 minutes at various
RPM settings. A magneto check was conducted at 1,700 rpm with normal rpm reductions noticed. In addition, the propeller was cycled twice with normal
results. The engine was advanced to full power and the propeller RPM was reduced with no anomalies noted. The engine was shut down normally using the
mixture control.
Examination of the propeller was conducted at the facilities of McCauley Propeller Systems, Wichita, Kansas, by representatives of McCauley Propeller
Systems, Cessna Aircraft, and the NTSB IIC on November 20, 2014. The examination revealed that the propeller had damage consistent with impact and low
rotational energy absorption. The propeller blades had leading edge impact damage, leading edge polishing and chordwise paint scratches.
The propeller exhibited no impact signature markings or component positions that would have indicated an angle disagreement between blades at impact. Both
propeller blades exhibited indications of functioning in the normal operating range at impact. The exact blade angles at the time of impact were not determined.
Internal examination of the propeller hub revealed that pitch change system continuity was confirmed from the piston to both blade shanks. One actuating link
was found fractured into two pieces. The failure of the actuating link was consistent with a tension overload type failure related to gross deflection of the blades
and the pitch change mechanism during the impact sequence.
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There was no evidence of any type of propeller failure or malfunction prior to the accident sequence.
The Woodward propeller governor, part number B210105, was retained and subsequently functionally tested using a test bench. During the bench test, no
anomalies were noted that would have precluded normal operation.
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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
Summary
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.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's inadequate control of
the airplane during the landing roll, which resulted in a runway excursion.
Events
2. Landing-landing roll - Nose over/nose down
1. Aircraft-Aircraft oper/perf/capability-Aircraft capability-Braking capability-Not attained/maintained - C
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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12/11/2014 2030 MST Regis# N961GW
Wendover, UT
Apt: Wendover ENV
Acft Mk/Mdl CESSNA 182T-T
Acft SN 18280961
Eng Mk/Mdl LYCOMING IO-540 SER
Acft TT
Fatal
Opr Name: PAUL BOWDEN
Opr dba:
2702
0
Ser Inj
2
Aircraft Fire: NONE
AW Cert: STN
Summary
After accomplishing a touch and go landing, during a moonless night, the pilot initiated a left climbing turn and orientated himself with the departure end of the
runway, by looking outside and behind the airplane. While looking outside, the pilot inadvertently put the airplane into a left steep bank and was unable to
recover. Prior to the airplane impacting terrain, which resulted in substantial damage to the fuselage and wings, the pilot reported that there were no preaccident
mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's failure to maintain
situational awareness during a turn which resulted in a loss of airplane control.
Events
1. Initial climb - Loss of control in flight
2. Personnel issues-Psychological-Perception/orientation/illusion-Situational awareness-Pilot - C
Narrative
After accomplishing a touch and go landing, during a moonless night, the pilot initiated a left climbing turn and orientated himself with the departure end of the
runway, by looking outside and behind the airplane. While looking outside, the pilot inadvertently put the airplane into a left steep bank and was unable to
recover. Prior to the airplane impacting terrain, which resulted in substantial damage to the fuselage and wings, the pilot reported that there were no preaccident
mechanical failures or malfunctions with the airplane that would have precluded normal operation.
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Accident Rpt# ANC15CA019
Acft Mk/Mdl CESSNA A185F-F
04/01/2015 1415 ADT Regis# N3885Q
Acft SN 18502207
Palmer, AK
Acft Dmg:
Fatal
Opr Name: CRUZ DAVID C
Page 32
0
Rpt Status: Prelim
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire:
All Rights Reserved
12/04/2014 1218 EST Regis# N756EB
Vero Beach, FL
Apt: Vero Beach Muni VRB
Acft Mk/Mdl CESSNA R182
Acft SN R18201046
Eng Mk/Mdl LYCOMING O-540
Acft TT
Fatal
Opr Name: FJ & B AERO LLC
Opr dba:
6301
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Summary
At the conclusion of a local flight, the pilot returned to his home airport and approached the runway for landing. The airplane touched down on the runway with
the main landing gear, bounced back into the air, and touched down a second time, with the nose landing gear striking the runway first. The nose landing gear
tire then separated from the landing gear, and the airplane continued down the runway on the wheel's rim. The remaining lower portion of the landing gear
subsequently broke away from the airplane, and the airplane eventually came to a stop on the runway. Federal Aviation Administration inspectors examined the
runway and airplane following the accident and estimated that the distance between the airplane's initial impact and where it eventually came to rest was about
300 feet. The separated portions of the nose landing gear were recovered from that portion of the runway, including the tire, wheel rim, landing gear fork, and
up-position microswitch. Post accident examination of the airplane revealed no evidence of any pre-impact mechanical malfunctions or failures that would have
precluded normal operation, and that the firewall and lower portion of the fuselage had been substantially damaged.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's improper landing
flare, resulting in a hard landing.
Events
Narrative
At the conclusion of a local flight, the pilot returned to his home airport and approached the runway for landing. The airplane touched down on the runway with
the main landing gear, bounced back into the air, and touched down a second time, with the nose landing gear striking the runway first. The nose landing gear
tire then separated from the landing gear, and the airplane continued down the runway on the wheel's rim. The remaining lower portion of the landing gear
subsequently broke away from the airplane, and the airplane eventually came to a stop on the runway. Federal Aviation Administration inspectors examined the
runway and airplane following the accident and estimated that the distance between the airplane's initial impact and where it eventually came to rest was about
300 feet. The separated portions of the nose landing gear were recovered from that portion of the runway, including the tire, wheel rim, landing gear fork, and
up-position microswitch. Post accident examination of the airplane revealed no evidence of any pre-impact mechanical malfunctions or failures that would have
precluded normal operation, and that the firewall and lower portion of the fuselage had been substantially damaged.
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Accident Rpt# ANC13FA090
08/29/2013 1300 AKD Regis# N9624S
Acft Mk/Mdl CHAMPION 7ECA
Acft SN 169
Eng Mk/Mdl LYCOMING O-235 SERIES
Opr Name: NORTON ADAM C
Sutton, AK
Apt: N/a
Fatal
2
Ser Inj
Opr dba:
0
Aircraft Fire: NONE
AW Cert: STN
Events
1. Maneuvering-low-alt flying - Aerodynamic stall/spin
Narrative
HISTORY OF FLIGHT
On August 29, 2013, about 1300 Alaska daylight time, a Champion 7ECA (Citabria) airplane, N9624S, sustained substantial damage following a collision with
terrain about 7 miles north of Sutton, Alaska. The private pilot and one passenger were fatally injured. The airplane was registered to, and operated by the pilot
as a visual flight rules personal local flight under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no
flight plan was filed. The flight originated from the Wolf Lake Airport, Palmer, Alaska, around 1200.
According to a family member of the pilot, the purpose of the flight was to scout for locations to hunt moose, and the pilot said that they would return later that
afternoon.
When the airplane did not return to Wolf Lake, a family member of the passenger reported the airplane overdue to the 11th Air Force's Rescue Coordination
Center (RCC) about 1930. The RCC initiated a search for the missing airplane along its supposed route of flight. In the early morning hours of August 30, an Air
National Guard C-130 Hercules was able to locate the wreckage. Rescue personnel aboard a HH-60G helicopter were able to reach the site later that morning,
and confirmed the pilot and passenger were deceased.
The pilot, age 30, held a private pilot certificate with a rating for airplane single engine land. He was issued a third class airman medical certificate on October
15, 2012.
No personal flight records were located for the pilot, and the aeronautical experience listed on page 3 of this report was obtained from Federal Aviation
Administration (FAA) airman records on file in the Aerospace Medical Certification Division in Oklahoma City, Oklahoma. On the pilot's most recent application
for a medical certificate, he indicated his total aeronautical experience was 84.2 hours, of which 1 hour was in the previous 6 months. Additional time logs
found in the accident airplane indicated a total additional flight time since the pilot's last medical of approximately 40 hours.
The two-seat, high-wing, fixed-gear airplane, serial number (S/N) 169, was manufactured in 1966. It was powered by a Lycoming O-235-C1 engine, rated at 115
horsepower, driving a two-bladed metal fixed pitch propeller. The aircraft logbooks were not located during the investigation.
A note found inside the airplane revealed that, on August 27, 2013, the airplane had an oil and filter change, new wheels installed, and a new starter installed.
The tachometer time for this maintenance was recorded at 112.0 hours. The tachometer time recorded at the accident site was 112.8 hours.
The closest weather reporting facility is the Palmer Airport, about 14 miles south of the accident site. At 1353, an Aviation Routine Weather Report (METAR)
was reporting, in part: Wind, 060 degrees (true) at 6 knots; visibility, 10 statute miles; clouds and sky condition, overcast at 10,000 feet; temperature, 57
degrees F; dew point, 48 degrees F; altimeter, 29.73 inches.
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The National Transportation Safety Board investigator-in-charge (IIC) along with an additional NTSB investigator reached the accident site on the morning of
August 31. The wreckage was located in an area of heavy alder brush, about 250 yards upslope of the floor of about a three mile wide mountain valley. The
area surrounding the accident site was interlaced with game trails, and there were numerous moose tracks and sign in the area. A large herd of moose was
also spotted in the same valley in the days after the accident.
The airplane came to rest upright, in a nose-low attitude, and was resting on several toppled and broken trees. The tail was against a tree supported by the
vertical stabilizer.
All control surfaces were identified at the accident site, and flight control continuity was verified from all of the flight control surfaces to the cockpit.
Both wings had spanwise leading edge crushing.
The empennage was mostly free of impact damage. The right elevator was resting against a tree and the trailing edge was crushed and bent upward.
The engine and propeller were partially buried in soft terrain; however the visible portions of the engine showed no anomalies to the case or accessories. The
visible portion of one propeller blade was relatively free of impact damage.
Both main landing gear were bent upward and aft from their connecting points and exhibited signs of left-side loading.
The cockpit area was extensively damaged. The engine and firewall were displaced upward and aft, and the instrument panel was displaced upward, almost to
the top of the windscreen. The mixture control was found in the full-forward position. The carburetor heat was in the off position. Throttle position could not be
determined due to damage to the throttle lever. The master switch was in the on position, and the both magneto switches were in the "ON" position.
A postmortem examination was conducted under the authority of the Alaska State Medical Examiner, Anchorage, Alaska, on September 3, 2013. The cause of
death for the pilot was attributed to multiple blunt force injuries.
The FAA's Civil Aeromedical Institute performed toxicological examinations for the pilot on October 7, 2013. The tests were negative for carbon monoxide and
alcohol, and positive for the following drugs:
0.2044 (ug/ml, ug/g) Tetrahydrocannabinol (Marihuana) detected in Lung
0.0871 (ug/ml, ug/g) Tetrahydrocannabinol (Marihuana) detected in Liver
0.0094 (ug/ml, ug/g) Tetrahydrocannabinol (Marihuana) detected in Blood
0.2495 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Liver
0.0146 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Urine
0.012 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Blood
0.0055 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Lung
Tetrahydrocannabinol (THC) is the psychoactive compound found in marijuana with therapeutic levels as low as 0.001 ug/ml. THC has mood altering effects
causing euphoria, relaxed inhibitions, sense of well-being, disorientation, image distortion, and psychosis. The ability to concentrate and maintain attention is
decreased during marijuana use, and impairment of hand-eye coordination is dose-related over a wide range of dosages. Impairment in retention time and
tracking, subjective sleepiness, distortion of time and distance, vigilance, and loss of coordination in divided attention tasks have all been reported. Users may
be able to "pull themselves together" to concentrate on simple tasks for brief periods of time. Significant performance impairments are usually observed for at
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least one to two hours following marijuana use, and residual effects have been reported up to 24 hours.
Tetrahydrocannabinol carboxylic acid is the inactive metabolite of tetrahydrocannabinol.
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06/23/2013 1101 PDT Regis# N169TM
Adrian, OR
Apt: N/a
Acft Mk/Mdl EXTRA 300/LT
Acft SN LT007
Eng Mk/Mdl LYCOMING AEIO-580-B1A
Acft TT
Fatal
Opr Name: EDWARD CLAUGUS
Opr dba:
59
1
Ser Inj
0
Aircraft Fire: NONE
Events
1. Maneuvering-low-alt flying - Low altitude operation/event
Narrative
HISTORY OF FLIGHT
On June 23, 2013, about 1101 Pacific daylight time, an experimental Extra Flugzeugproduktions EA 300/LT, N169TM, collided in flight with power lines near
Adrian, Oregon. The pilot/owner was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The private pilot sustained
fatal injuries; the airplane sustained substantial damage from impact forces. The local personal flight departed Ontario, Oregon, at an undetermined time. Visual
meteorological conditions (VMC) prevailed, and no flight plan had been filed.
A witness was preparing to fish when he heard the airplane's engine. He observed the airplane fly through the river canyon above him; it was following the
contours of the canyon. He saw the airplane collide with large power lines (5/8-inch cable) across the Owyhee River, about 1/2 mile down river from the
Owyhee Dam. The airplane continued on, but he could not see it any longer due to the canyon walls.
Another witness was fishing, and heard the airplane come around a corner downriver from him. He thought that the pilot initiated a climb to avoid the power
lines. The airplane went into a flat spin, and flew into the power lines before contacting the ground.
Another witness, who is a private pilot, was fishing about 2 miles away. He heard the engine get extremely loud, and thought that meant that the airplane was
descending rapidly. He observed the airplane flying in the area the previous day, and estimated its speed at 200 miles per hour.
A first responder reported that the pilot was in the rear seat, and they observed scratch marks from a wire on the left wing.
A Federal Aviation Administration (FAA) inspector examined the wreckage on scene. The airplane came to rest upright. There was extensive damage to the
airplane forward of the wings. The landing gear collapsed downward. The power lines were marked with orange spherical balls.
The Malheur County Medical Examiner authorized an autopsy by the Saint Alphonsus Medical Center-Ontario Department of Pathology. The FAA Forensic
Toxicology Research Team, Oklahoma City, Oklahoma, performed toxicological testing of specimens of the pilot.
Analysis of the specimens contained no findings for carbon monoxide or volatiles. They did not perform tests for cyanide.
The report contained the following findings for tested drugs: Atorvastatin detected in urine, Atorvastatin not detected in blood; 0.07 (ug/ml, ug/g) morphine
detected in urine, morphine not detected in blood (cavity); Ramipril detected in urine, Ramipril not detected in blood.
Ramipril was used to treat high blood pressure, and Atorvastatin was used to treat elevated cholesterol.
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Accident Rpt# ERA14FA044
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
Summary
According to the pilot's wife, the pilot departed on a cross-country flight to attend a friend's funeral. He told her that he intended to stop to purchase fuel at an
airport 20 miles from the departure airport. Although she reported that the pilot had indicated to her the night before the accident that he was concerned about a
cold front that was moving in, it could not be determined whether he consulted any weather resources before the flight, and there was no record that he
obtained an official preflight weather briefing. The pilot departed without filing an instrument flight rules flight plan for the flight; instrument meteorological
conditions existed at the time of departure.
A witness at the departure airport reported that he observed an airplane taxiing and heard it depart and that the weather at the time was very foggy. A review of
air traffic control radar data showed the airplane 1 mile north of the departure airport tracking northwest toward the intended fuel stop destination, and the last
radar target was 8 miles northwest of the departure airport. The airplane's wreckage was located in a wooded area resting nose-down at the base of a tree 1/2
mile from the destination airport. All flight control surfaces and major components were located at the accident site. Postaccident examination of the airframe
and engine revealed no anomalies that would have precluded normal operation.
The reported weather conditions at both airports about the time of the accident included low ceilings and low visibility; fog was reported at the destination
airport, and the departure airport had been reporting overcast ceilings at 200 ft above ground level for several hours before the flight departed. It is likely that
the pilot placed pressure upon himself to make the flight because he was going to attend his friend's funeral.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's loss of control in
instrument meteorological conditions for reasons that could not be determined because examination of the airframe and engine revealed no anomalies that
would have precluded normal operation. Contributing to the accident was the pilot's self-induced pressure to make the flight.
Events
1. Approach - Controlled flight into terr/obj (CFIT)
1. Environmental issues-Conditions/weather/phenomena-Ceiling/visibility/precip-Fog-Effect on operation
2. Personnel issues-Psychological-Personality/attitude-Motivation/respond to pressure-Pilot - F
3. Personnel issues-Psychological-Mental/emotional state-Stress-Pilot
5. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-(general)-Not attained/maintained - C
6. Environmental issues-Conditions/weather/phenomena-Ceiling/visibility/precip-Low ceiling-Effect on operation
7. Environmental issues-Conditions/weather/phenomena-Ceiling/visibility/precip-Low visibility-Effect on operation
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
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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
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.
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WRECKAGE INFORMATION
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
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
have precluded normal operation.
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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
Summary
Witnesses reported observing the twin-engine amphibious airplane flying southbound low above a river and hearing the engine running. The airplane then made
a 180-degree left turn, which was consistent with the pilot flying a tight traffic pattern before attempting a water landing. The airplane then descended, leveled
off above the water, and suddenly banked left. The airplane's nose and left pontoon then struck the water, and the airplane nosed over, caught fire, and sank.
Postrecovery examination of the wreckage revealed that the landing gear was in the "up" position and that the flaps were extended, which indicates that the
airplane had been configured for a water landing. No evidence of any preimpact failures or malfunctions of the airplane or engines was found that would have
precluded normal operation. At the time of the accident, a light breeze was blowing, the river was at slack tide, and the water conditions were calm, all of
which were conducive to glassy water conditions. It is likely that the glassy water conditions adversely affected the pilot's depth perception and led to his
inability to correctly judge the airplane's height above the water. He subsequently flared the airplane too high, which resulted in the airplane exceeding its
critical angle-of-attack, entering an aerodynamic stall, and impacting the water in a nose-low attitude.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's misjudgment of the
airplane's altitude above the water and early flare for a landing on water with a glassy condition, which led to the airplane exceeding its critical angle-of-attack
and experiencing an aerodynamic stall.
Events
1. Landing - Aerodynamic stall/spin
2. Uncontrolled descent - Collision with terr/obj (non-CFIT)
3. Other - Dragged wing/rotor/float/other
4. Other - Nose over/nose down
5. Post-impact - Fire/smoke (post-impact)
2. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Descent/approach/glide path-Not attained/maintained - C
3. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Airspeed-Not attained/maintained - C
4. Environmental issues-Physical environment-Runway/land/takeoff/taxi surface-Glassy-Effect on personnel - C
6. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Angle of attack-Not attained/maintained - C
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
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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.
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.
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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.
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.
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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
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.
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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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06/18/2014 1930 EDT Regis# N891JC
Acft Mk/Mdl GRUMMAN ACFT ENG COR-SCHWEIZER Acft SN 193B
Eng Mk/Mdl PRATT AND WHITNEY R-1340-AN1
Acft TT
Opr Name: CHORMAN SPRAYING LLC
Opr dba:
12108
Farmington, DE
Apt: Chorman D74
Fatal
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: SPR
Events
1. Initial climb - Aerodynamic stall/spin
Narrative
HISTORY OF FLIGHT
On June 18, 2014, about 1930 eastern daylight time, a Grumman Aircraft G-164B, N891JC, impacted the ground during a forced landing shortly after takeoff
near Chorman Airport (D74), Farmington, Delaware. The airplane was owned and operated by Chorman Spraying, LLC as an aerial application flight. The
commercial pilot received minor injuries and the airplane sustained substantial damage to the fuselage and empennage. Visual meteorological conditions
prevailed and no flight plan had been filed for the local flight, which was operated under the provisions of Title 14 Code of Federal Regulations Part 137. The
flight was originating at the time of the accident.
According to the pilot, he flew the airplane in the morning and returned to the airport about 1900, to load the hopper tank with insecticide and water, for a flight
to a nearby watermelon farm. After loading the product and fueling the airplane, he taxied out, performed the required pre-takeoff checklist items, and departed
to the north. After departure, he maneuvered the airplane in order to climb out to the right of the runway's extended centerline to avoid overflying a residence.
He further reported that he reduced the manifold pressure back to 32 inches and the propeller speed to about 2,000 rpm. Approximately 150 feet above ground
level, he commanded a slight left bank towards the west and immediately the airplane started to "settle." The pilot leveled the wings; however, the airplane
started an uncommanded right bank "similar to entering a stall." He attempted to pull the product "dump" handle, but inadvertently activated the "spray" handle.
He then attempted to pull the dump handle again, but was unable to do so due to the airplane's close proximity to the ground. The airplane subsequently
impacted a field, nosed over, and came to rest inverted.
According to the pilot and Federal Aviation Administration (FAA) records, the pilot held a commercial pilot certificate with a rating for airplane single-engine
land, multiengine land, and instrument airplane. He also held a flight instructor certificate for airplane single and multiengine land, and instrument airplane. The
pilot's most recent second-class medical certificate was issued on October 24, 2013. According to the pilot, he had accumulated 2,306 hours of total flight time
and 573 hours of flight time in the accident airplane make and model.
According to the pilot and the operator's records, the single-engine, tailwheel-equipped biplane was manufactured in 1977. It was powered by a Pratt and
Whitney radial engine with 10,125 hours of time in service and 553.53 hours since major overhaul. The most recent annual inspection was recorded on May 8,
2014.
METEROGOLOGICAL INFORMATION
The 1854 recorded weather observation at Sussex County Airport (GED), Georgetown, Delaware, located 15 miles to the southeast of the accident location,
included wind from 210 degrees at 8 knots, visibility 10 miles, clear skies, temperature 33 degrees C, dew point 20 degrees C; barometric altimeter 29.96
inches of mercury. The density altitude was about 2,100 feet.
AIRPORT INFORMATION
The airport was a privately owned airport and at the time of the accident did not have a control tower. It was equipped with a single runway designated 16/34.
The runway was 3,588 feet long and 37 feet wide and the runway surface was considered "in poor condition." The airport elevation was 66 feet above mean
sea level.
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Examination of the airplane by a FAA inspector, following the airplane's recovery from the field, revealed that the airplane's fuselage, vertical stabilizer, and
rudder were substantially damaged. Rotation of the engine, by hand, was accomplished utilizing the propeller hub, which revealed continuity through the engine
and thumb compression on some of the cylinders. However, there was no rotation through the supercharger and the impeller was not rotating.
TEST AND RESEARCH
The engine was examined, under the supervision of the NTSB Investigator-in-Charge, and during the examination the engine was noted as exhibiting minimal
damage. When the engine was rotated by hand, utilizing a crankshaft turning bar, some internal binding was noted and the impeller did not rotate. Thumb
compression was observed on all cylinders. Due to the internal binding, an engine run was not possible and the engine was disassembled. During the
disassembly it was noted that the intermediate gear had three teeth that were impact sheared, and further examination of the gear revealed no other damage.
Examination of the engine revealed no evidence of preimpact anomalies that would have precluded normal operation. For a detailed report on the engine
examination refer to the public docket for this accident.
According to the pilot and operator, the airplane was fueled with 80 gallons of fuel and had 250 gallons of product in the forward hopper tank, just prior to
departure. The airplane weight at the time of the accident was about 6,934 pounds, and the maximum gross weight for the airplane was 7,564 pounds.
Density Altitude
Pilot's Handbook of Aeronautical Knowledge (FAA-H-8083-25A) noted that density altitude represents pressure altitude corrected for nonstandard temperature.
A decrease in air density corresponds with an increase in density altitude and a decrease in airplane performance. Density altitude is used in calculating
airplane performance.
FAA Pamphlet FAA-P-8740-2 (2008), "Density Altitude," defines density altitude as "pressure altitude corrected for non-standard temperature variations."
Density altitude can affect aircraft performance. As density altitude increases, air density decreases, which results in decreased aircraft performance.
According to the Koch chart on page 3 of the pamphlet, and based on the conditions at the time of the accident, 91 degrees F and pressure altitude of about
sea level, the airplane's climb rate would have been reduced by about 20 percent.
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03/23/2015 1545 EDT Regis# N936B
Acft Mk/Mdl HAWKER BEECHCRAFT CORP G36
Acft SN E-3774
Eng Mk/Mdl CONT MOTOR IO-550-B
Opr Name: ASSOCIATED PACKAGING INC
Inverness, FL
Apt: N/a
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
1
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: STU
Events
1. Enroute-cruise - Loss of engine power (partial)
Narrative
On March 23, 2015, at 1545 eastern daylight time, a Hawker Beechcraft G36, N936B, was substantially damaged when it struck a residence during a forced
landing near Inverness, Florida. The private pilot was seriously injured. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was
filed for the flight, which originated from Marco Island Airport (MKY), Marco Island, Florida and was destined for Ocala International Airport (OCF), Ocala,
Florida. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.
According to preliminary air traffic control (ATC) radar and voice communication information provided by the Federal Aviation Administration, the pilot departed
from MKY about 1425. The flight proceeded uneventfully, and at 1539, was given a radar vector toward an initial approach fix for the RNAV (GPS) RWY 18
instrument approach to OCF. About 30 seconds later, the airplane began descending from its previously established altitude of 6,000 feet, and at 1540, the pilot
advised ATC, "we've got an engine problem, I see a runway off to my left, what is it?" The controller then advised the pilot that the airport he was referencing
was Inverness Airport (INF), Inverness, Florida. The pilot responded that he believed the airplane would be able to reach its originally intended destination of
OCF, and asked to be routed directly there. The controller advised the pilot that INF was located to his 11-o'clock and 5 miles, while OCF was located to his
12-o'clock and 20 miles. The pilot again requested and was provided with a radar vector to OCF.
By 1541, the airplane had descended to an altitude of 4,000 feet. About that time, the controller asked the pilot to report the number of persons aboard and the
airplane's quantity of fuel remaining. The pilot stated that there was one person onboard, that the airplane had 3 hours of fuel remaining, and "we've got an
engine that's cutting out." The controller again offered that INF was located to the pilot's 9-o'clock and 4 miles, to which the pilot responded, "we're going there
now." The controller subsequently provided the pilot with the runway orientation at INF, and cleared him for a visual approach. The pilot acknowledged the
transmission, and no further communications were received from the pilot. Radar contact with the airplane was lost at 15:43:45, at a reported altitude of 800
feet, about 2 nautical miles north east of the INF runway 19 threshold. The airplane subsequently impacted a residence located about 1 nautical mile southwest
of the last radar-observed position, and about 1 nautical mile northeast of the runway 19 threshold.
The wreckage was subsequently recovered from the accident site and retained for examination at a later date.
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03/28/2015 1800 PDT Regis# N130HA
Acft Mk/Mdl HILLER UH 12E-UNDESIGNAT
Opr Name: MID-CAL AG AVIATION INC
Acft SN HA3030
Firebaugh, CA
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
0
Prob Caus: Pending
Aircraft Fire: NONE
Events
1. Maneuvering-low-alt flying - Loss of engine power (partial)
Narrative
On March 28, 2015, about 1800 Pacific daylight time, a Hiller UH-12E, N130HA, sustained substantial damage following a partial loss of engine power and
subsequent forced landing approximately 6 miles east of Firebaugh, California. The pilot, the sole occupant, was not injured. The helicopter was registered to
Mid-Cal AG Aviation, Inc., and was operated as an agricultural aerial application flight under the provision of 14 Code of Federal Aviation Regulation (CFR) Part
137. Day visual meteorological conditions prevailed, and no flight plan had been filed. The local flight originated from the loading site approximately 6 miles east
of Firebaugh, about 1700.
The pilot reported that during a landing sequence, the helicopter's engine momentarily sounded rough. The pilot landed without incident, refueled, and departed
for another application flight. However, towards the end of the application, the pilot heard the same engine noise as during the previous flight, and subsequently
experienced a loss of engine power. The pilot initiated an emergency autorotation to a field, and impacted trees, which resulted in substantial damage to the
fuselage and the tailboom.
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04/01/2015 2030 UTC Regis# N777XX
Acft Mk/Mdl LANCAIR COMPANY LC 40 550FG-550FG Acft SN 40058
Opr Name: AHMED AL-NIAIMI
Page 50
Middleton, WI
Apt: Middleton Muni - Morey Field C29
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire: NONE
All Rights Reserved
03/28/2014 830 CDT
Acft Mk/Mdl MAULE MX 7-180B-180B
Opr Name: PARTHENON LLC
Regis# N10503
Dora, AR
Acft SN 22016C
Acft TT
Fatal
726
0
Apt: N/a
Ser Inj
Opr dba:
0
Aircraft Fire: NONE
AW Cert: STN
Events
1. Takeoff - Loss of control in flight
Narrative
The pilot performed one stop and go landing on the unimproved landing area. During the second landing attempt he bounced the initial landing, added power to
recover, and attempted to land again about midfield. The pilot evaluated the distance remaining and elected to go around. After adding power and committing to
the takeoff, the pilot recognized he would not be able to maintain obstacle clearance and attempted to maneuver to a fly over a low fence crossing. The
airplane impacted the fence, and came to an immediate stop. The airplane's right main landing gear was bent aft resulting in substantial damage to the
fuselage. The pilot reported no anomalies with the airplane prior to the accident.
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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
Summary
According to air traffic control records, during the cross-country flight, the pilot reported that the engine had lost oil pressure. About 10 minutes later, he
reported that the engine was running roughly and that there was smoke in the cockpit. He then stated that he was shutting down the engine. The pilot then
made a forced landing in rough terrain. An examination of the wreckage site revealed black viscous fluid on the belly of the fuselage from the engine
compartment to the tail skid. The ground underneath the fuselage was also stained with black fluid.
Postaccident examination of the engine determined that several of the connecting rod journals and the No. 2 connecting rod had overheated and that the No. 2
connecting rod had fractured and separated. A nonstandard shim was found installed between the propeller hub and the crankshaft propeller flange. A review of
the maintenance logbooks found no documentation or entries indicating when the nonstandard shim was manufactured or installed nor who made it. Further
examination revealed that the No. 1 main bearing journal and crankshaft propeller flange were misaligned relative to the Nos. 2 and 3 main bearing journals and
that the crankshaft was bent. The orientation of the misalignment in both the flange and the No. 1 journal matched, indicating that they were related. The
thickness variation in the shim also matched the orientation and magnitude of the propeller flange misalignment, indicating that it had been machined to
compensate for the flange misalignment. The heat tinting observed on the connecting rod journals and on the No. 2 connecting rod was consistent with
overheating of the bearings typically associated with either improper clearance or insufficient oil pressure at the bearing surface. The misalignment of the
crankshaft likely affected both the clearances and the oil pressures at the connecting rod bearings, which led to the overheating of the bearings during flight.
The continued use of a bent crankshaft led to the secondary failure of the No. 2 connecting rod.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The manufacture and installation
of a nonstandard part by unknown maintenance personnel to compensate for a bent, misaligned crankshaft propeller flange, which resulted in the improper
clearance of the bearings on the crankshaft journal, a loss of oil pressure, overheating of the bearings, and the failure of a connecting rod during cruise flight.
Events
1. Enroute-cruise - Loss of engine power (total)
2. Landing-flare/touchdown - Off-field or emergency landing
1. Aircraft-Aircraft power plant-Engine (reciprocating)-Recip engine power section-Incorrect service/maintenance - C
2. Personnel issues-Task performance-Maintenance-Modification/alteration-Other/unknown - C
3. Environmental issues-Physical environment-Terrain-Mountainous/hilly terrain-Contributed to outcome
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.
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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.
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
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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.
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.
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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
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.
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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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10/23/2013 1130 CDT Regis# N4151D
Acft Mk/Mdl NORTH AMERICAN P 51D
Acft SN 44-73458A
Eng Mk/Mdl PACKARD V-1650
Opr Name: LONE STAR FLIGHT MUSEUM
Galveston, TX
Apt: N/a
Fatal
2
Ser Inj
Opr dba:
0
Aircraft Fire: NONE
Events
1. Enroute - Controlled flight into terr/obj (CFIT)
Narrative
On October 23, 2013, about 1130 central daylight time, a North American P-51D airplane, N4151D, impacted the waters of Galveston Bay near Galveston,
Texas. The airline transport rated pilot and passenger were fatally injured and the airplane was substantially damaged. The airplane was registered to the
Texas Aviation Hall of Fame, Galveston, Texas, and operated by the Lone Star Flight Museum, Galveston, Texas, under the provisions of 14 Code of Federal
Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed and a flight plan was not filed for the flight. The flight originated from the
Scholes International Airport (KGLS), Galveston, Texas, about 1120.
A review of air traffic control (ATC) communications, revealed routine radio communications between ATC and the pilot. Shortly after takeoff, the KGLS tower
controller queried the pilot if he wanted to contact Houston Center after leaving the control tower's airspace or remain on the tower frequency. The pilot reported
that they would be airborne for 25-30 minutes and would remain on the tower controller's frequency. There was no further communication between the pilot and
ATC.
A witness, who was on a fishing boat, reported that he heard the airplane overhead heading south. The airplane made a slow turn to the north. The witness
added that it appeared the airplane was descending and traveling at a high rate of speed. The engine sounded like it was at full throttle and the wings were level
before impact with the water.
A review of radar data for the accident flight depicted the airplane departing KGLS and climbing. The airplane's track showed the airplane maneuvering and
generally heading southwest, over the water of West Bay. The airplane reached an altitude of 3,500 feet, and then descended to 2,800 feet with airspeed about
200 knots, before the radar data ended.
The accident site was located about 13 miles southwest of KGLS, in shallow water between West Bay and Chocolate Bay. The winds at the time of the
accident were reported as light.
The airplane fragmented upon impact with the water. The engine, propeller, both wings, pieces of the fuselage, and a majority of the empennage were
recovered; the remainder of the wreckage was not recovered.
The airplane was equipped with an on-board video recording system. The system records two camera views along with audio. One fish-eye lensed camera is
mounted in the vertical stabilizer and captures a view of the airplane and horizon. The fish-eye camera view is looking forward, with the cockpit canopy in the
center; images of the surrounding terrain can generally be seen in the background. The second camera is mounted in the cockpit and captures a view of the
rear seat occupant. The system records an inset image of the passenger in the lower right portion of the airplane view.With the assistance of the Galveston
County Sheriff Office, Marine Patrol and the Federal Bureau of Investigations Evidence Response Team, the video recording unit with SD card was located in
the wreckage, and recovered from the bay. The unit was shipped to the National Transportation Safety Board (NTSB)'s Vehicle Recorder Laboratory in
Washington, DC.
A video file was recovered from the SD card that captured the accident flight. A video group that consisted of representatives from the NTSB, Federal Aviation
Administration and the operator was convened in at the NTSB Recorders Laboratory, Washington, DC, to view and document the video. The video depicted the
airplane's departure and flight over the bay; the video also captures the conversation between the pilot, air traffic control, and the passenger. After leveling off,
the pilot demonstrated several turns. After a few minutes, the pilot asked the passenger if he'd like to fly the airplane. The passenger stated he was not a pilot,
but he'd like to try it. With the passenger on the controls, the pilot explained left and right turns. The airplane was viewed maneuvering with reference to the
conversation between the pilot and passenger [A full detailed transcript of the video and audio is available in the NTSB public docket]. With the passenger still
at the controls, the airplane was seen steeply banking to the right to almost 90 degrees, with the nose of the airplane dropping; the pilot explained that back
pressure is needed during turns, to prevent the loss of lift. The conversation continued as the airplane was rolling wings level and the pilot was encouraging the
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passenger to pull back on the stick. During this time, the video depicted the airplane in a descent towards the water. Neither the pilot nor passenger
acknowledged the impending collision. The review of the video also noted that the surface of the bay's water appeared smooth, almost glass like. The video did
not capture the actual impact with the water, due to a delay in the recording to the SD card and the interruption of power to the unit.
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02/22/2015 1125 PST Regis# N4155U
Camarillo, CA
Apt: Camarillo CMA
Acft Mk/Mdl PIPER PA 18-150
Acft SN 1809068
Eng Mk/Mdl LYCOMING O-360-C4P
Acft TT
Fatal
Opr Name: PETER J. RYAN
Opr dba:
723
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Summary
The pilot stated that he was practicing touch-and-go takeoffs and landings. During the second landing the pilot failed to maintain directional control. The airplane
subsequently departed the side of the runway, and ground looped, which resulted in substantial damage to the left wing and left lift strut.
The pilot reported there were no pre-impact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operations.
Cause Narrative
directional control during the landing roll.
Events
Narrative
The pilot stated that he was practicing touch-and-go takeoffs and landings. During the second landing the pilot failed to maintain directional control. The airplane
subsequently departed the side of the runway, and ground looped, which resulted in substantial damage to the left wing and left lift strut.
The pilot reported there were no pre-impact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operations.
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05/23/2014 1230
Acft Mk/Mdl PIPER PA 22-UNDESIGNAT
Regis# N3460A
Roundup, MT
Acft SN 22-1744
Fatal
Opr Name: JOHN BAKE
0
Ser Inj
Opr dba:
0
Aircraft Fire: NONE
AW Cert: STN
Summary
The pilot reported that during takeoff from a 1,200-foot long turf airstrip, the airplane accelerated beyond a speed he anticipated for rotation and remained on
the ground. Despite the pilot's attempt to abort the takeoff and stop the airplane, it overran the departure end of the runway and struck multiple trees before it
came to rest upright. The fuselage and both wings were substantially damaged. The pilot stated that at the time of the accident, it was unseasonably warm and
the degradation of the airplane's performance was significantly more than he had anticipated. The pilot reported no mechanical malfunctions or failures with the
airplane that would have precluded normal operation.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's delayed action to
abort the takeoff. Contributing to the accident was the pilot's inadequate preflight planning and a high density altitude.
Events
1. Takeoff-rejected takeoff - Runway excursion
2. Takeoff-rejected takeoff - Collision with terr/obj (non-CFIT)
1. Personnel issues-Task performance-Use of equip/info-Use of equip/system-Pilot - C
2. Personnel issues-Action/decision-Action-Delayed action-Pilot - C
3. Environmental issues-Conditions/weather/phenomena-Temp/humidity/pressure-High density altitude-Effect on operation - F
4. Personnel issues-Task performance-Planning/preparation-Performance calculations-Pilot - F
5. Environmental issues-Physical environment-Object/animal/substance-Tree(s)-Not specified
Narrative
The pilot reported that during takeoff from a 1,200-foot long turf airstrip, the airplane accelerated beyond a speed he anticipated for rotation and remained on
the ground. Despite the pilot's attempt to abort the takeoff and stop the airplane, it overran the departure end of the runway and struck multiple trees before it
came to rest upright. The fuselage and both wings were substantially damaged. The pilot stated that at the time of the accident, it was unseasonably warm and
the degradation of the airplane's performance was significantly more than he had anticipated. The pilot reported no preimpact mechanical malfunctions or
failures with the airplane that would have precluded normal operation.
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03/29/2015 1334 EDT Regis# N6842W
West Chester, PA
Acft Mk/Mdl PIPER PA 28-140
Acft SN 28-20985
Acft Dmg: DESTROYED
Eng Mk/Mdl LYCOMING 0-320-E2A
Acft TT
Fatal
Opr Name: DEAL JOSEPH J
Opr dba:
2749
2
Ser Inj
Apt: Brandywine Airport OQN
Rpt Status: Prelim
0
Prob Caus: Pending
Aircraft Fire: GRD
AW Cert: STN
Events
2. Takeoff - Loss of engine power (partial)
Narrative
On March 29, 2015, about 1334 eastern daylight time, a Piper PA-28-140, N6842W, registered to and operated by a private individual, crashed shortly after
takeoff from Brandywine Airport (OQN), West Chester, Pennsylvania. Visual meteorological conditions prevailed at the time and no flight plan was filed for the
14 CFR Part 91 personal, local flight. The airplane was destroyed by impact and a postcrash fire, and the certified flight instructor and private-rated pilot were
fatally injured. The flight was originating at the time of the accident.
The purpose of the flight was a flight review for the airplane owner, who had reportedly not flown since 2011. One witness on the airport reported hearing a
rough running engine during a check of one magneto during an engine run-up, but the condition cleared up during a second magneto check after leaving the
engine operating at a higher rpm for a period of time.
A takeoff from runway 27 was initiated, but by one witness account, the takeoff was aborted and the airplane was taxied off the runway at the second turn off.
The witness did not hear any abnormal engine sounds associated with the aborted takeoff. The airplane was taxied to the approach end of runway 27, and no
engine run-up was heard being performed. During takeoff, several witnesses reported hearing sputtering from the engine at a point when the airplane was about
midpoint of the runway. The witness descriptions varied likely based on their locations in relation to the airplane whether the airplane was on the runway or just
above it when the sputtering occurred. One witness who was located south of the runway described the sputtering as significant, while a second witness
described it lasting 3 to 4 seconds while the airplane was only 2 to 3 feet above ground level. The nose of the airplane was observed to lower and engine power
was heard to be restored.
The flight continued, and by several witness accounts, the airplane began to climb and the sputtering or popping sounds resumed. The airplane at that time by
witness accounts was either _ down the runway, or west of the runway over 202. One witness did not observe any smoke trailing the airplane during the second
sound of pops, and he could not tell if the engine continued to run. The airplane was observed struggling "to maintain altitude" with one witness stating the
airplane never climbed higher than 200 feet. The airplane was observed by several witnesses in a left turn that steepened to what one witness described as
wings vertical. The airplane was then observed to pitch nose down, and impacted the back yard of a residence. A postcrash fire began about 10 seconds after
impact, which was extinguished by fire rescue.
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01/04/2015 1015 MST Regis# N3811M
Sedona, AZ
Apt: Sedona SEZ
Acft Mk/Mdl PIPER PA 28R-200
Acft SN 28R-35200
Eng Mk/Mdl LYCOMING IO360 SER
Acft TT
Fatal
Opr Name: D I V A 1336 LLC
Opr dba:
5059
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Summary
The pilot departed his local airport for a personal cross-country flight. The runway at the landing airport was oriented north/south. The pilot stated that the
weather at the time of his arrival was clear with calm wind, and that under those conditions aircraft generally land and takeoff to the north since the runway
slopes upward in that direction. However, that day, aircraft in the traffic pattern were landing and taking off to the south. The pilot made a decision to follow the
direction of prevailing traffic, flying and landing to the south. After landing, he applied the brakes to compensate for the sloped terrain. At the same time, the left
wheel rolled over unidentified debris on the runway, which caused the pilot to lose directional control. The airplane veered off the left side of the runway,
sustaining substantial damage to the left wing. The pilot reported that there were no mechanical malfunctions or failures with the airplane that would have
precluded normal operation.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's loss of directional
control during the landing roll.
Events
Narrative
The pilot departed his local airport for a personal cross-country flight. The runway at the landing airport was oriented north/south. The pilot stated that the
weather at the time of his arrival was clear with calm wind, and that under those conditions aircraft generally land and takeoff to the north since the runway
slopes upward in that direction. However, that day, aircraft in the traffic pattern were landing and taking off to the south. The pilot made a decision to follow the
direction of prevailing traffic, flying and landing to the south. After landing, he applied the brakes to compensate for the sloped terrain. At the same time, the left
wheel rolled over unidentified debris on the runway, which caused the pilot to lose directional control. The airplane veered off the left side of the runway,
sustaining substantial damage to the left wing. The pilot reported that there were no mechanical malfunctions or failures with the airplane that would have
precluded normal operation.
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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
Eng Mk/Mdl CONT MOTOR TSIO-360 SER
Acft TT
Fatal
Opr Name: TEFFT WADE H
Opr dba:
4106
1
Ser Inj
0
Aircraft Fire: NONE
Summary
Witnesses reported observing the pilot taxi the airplane from inside his hangar and depart. For several minutes, the airplane maneuvered at a low altitude and
high airspeed. Witnesses then observed the airplane make a steep bank turn, descend, and impact terrain about 5 miles east of the departure airport. The
pilot's wife had reported to local law enforcement that she believed he had committed suicide. The pilot's wife reported that she had recently informed him that
she wanted a divorce and was purchasing another home. She added that, about 5 years earlier, the pilot had told her that, if she ever left him, he would fly his
airplane into the ground and kill himself. Although the wreckage was significantly fragmented, no evidence of any preimpact mechanical malfunctions or failures
of the airframe or engine were noted that would have precluded normal operation. The medical examiner determined that the pilot's manner of death was
"suicide."
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's intentional descent
into the terrain.
Events
1. Maneuvering - Security/criminal event
2. Maneuvering - Controlled flight into terr/obj (CFIT)
1. Personnel issues-Miscellaneous-Intentional act-Suicide-Pilot - C
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.
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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.
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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02/16/2015 1445 CST Regis# N727SC
Chicago, IL
Apt: Chicago Midway International MDW
Acft Mk/Mdl PIPER PA 31-350-350
Acft SN 31-7305110
Eng Mk/Mdl LYCOMING LTI0-540-J2BD
Acft TT
Fatal
Opr Name: SOLUTIONS AIR CHARTER
Opr dba:
13600
0
Ser Inj
0
Aircraft Fire: NONE
Events
1. Landing-landing roll - Landing gear collapse
Narrative
On February 16, 2015, at 1445 central standard time, a Piper PA-31-350 airplane, N727SC, sustained substantial damage following a collapse of the nose and
right main landing gear during landing at Chicago Midway International Airport (MDW), Chicago, Illinois. The airline transport pilot, who was the sole occupant,
was not injured. The airplane was registered to Pinot Leasing, LLC, Zionsville, Indiana, and operated by Solutions Air Charter, Greenfield, Indiana. Visual
meteorological conditions prevailed at the time of the accident and an instrument flight rules flight plan was filed for the 14 Code of Federal Regulations Part 91
positioning flight. The airplane departed the Indianapolis Regional Airport (MQJ), Indianapolis, Indiana, at 1445 eastern standard time, and was destined for
MDW.
The pilot reported that he executed a normal approach for landing to runway 4R at MDW. During the approach, the pilot lowered the landing gear and verified
the extended position with the landing gear position indicators in the cockpit. Upon touchdown on the runway, the nose landing gear collapsed, followed by a
collapse of the right main landing gear. The airplane exited the runway surface and came to rest upright.
According to the Federal Aviation Administration (FAA) inspector who examined the airplane, the right wing sustained substantial damage to the forward and aft
spars.
On March 2, 2015, the airplane was examined by a National Transportation Safety Board investigator, a FAA inspector, and representatives from the operator.
At the time of the examination, the airplane was located on an outside ramp surface with its landing gear extended and secured with straps and harness
equipment. The airplane is equipped with a hydraulically actuated, retractable tricycle landing gear, and the landing gear system was visually examined. The
airplane's hydraulic reservoir, located in the forward baggage compartment, did not exhibit fluid in its sight glass. The sight glass was removed and fluid was
observed on a removed strip that was lowered into the sight glass opening. No evidence was found that the hydraulic system was compromised during the
accident.
During the examination, the airplane power was switched on, the landing gear handle was lowered, and landing gear emergency extension was performed.
During the landing gear emergency extension, the landing gear locked into the extended position and the right main inner landing gear door moved to the up
position. The left main landing gear door actuator was separated from its door. Due to the unavailability of equipment to properly support the airplane, a test of
landing gear retraction and extension operations was not performed. The examination of the landing gear system revealed no evidence of mechanical
malfunctions or failures that would have precluded normal operation.
The airplane's most recent annual inspection was completed on October 1, 2014.
According to the Airplane Flight Manual (AFM), the hydraulic system fluid level of the reservoir should be checked every 50 hours by placing the airplane in a
level position and viewing the fluid level through the sight glass located in the forward surface of the reservoir dome. If fluid is not visible, filtered hydraulic fluid
(MIL-H-5606) should be added. The AFM preflight inspection checks do not include verifying the hydraulic fluid level in the sight gauge.
According to a FAA inspector who spoke with a Piper technical service representative, the amount of hydraulic fluid found in the accident airplane at the time of
the examination would not impact the operation of the landing gear system.
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04/27/2014 2116 CDT Regis# N8700E
Highmore, SD
Apt: N/a
Acft Mk/Mdl PIPER PA 32R-300
Acft SN 32R-7680159
Acft Dmg: DESTROYED
Eng Mk/Mdl LYCOMING IO-540-K1G5D
Acft TT
Fatal
Opr Name: FISCHER DONALD J
Opr dba:
4766
4
Ser Inj
0
Aircraft Fire: GRD
Events
1. Enroute - Controlled flight into terr/obj (CFIT)
Narrative
HISTORY OF FLIGHT
On April 27, 2014, about 2116 central daylight time (CDT), a Piper PA-32R-300 airplane, N8700E, was destroyed during an impact with the blades of a wind
turbine tower 10 miles south of Highmore, South Dakota. The commercial pilot and three passengers were fatally injured. The airplane was registered to and
operated by a private individual under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Dark night instrument meteorological
conditions prevailed for the flight, which operated without a flight plan. The flight originated from Hereford Municipal Airport (KHRX), Hereford, Texas,
approximately 1700, and was en route to Highmore Municipal Airport (9D0), Highmore, South Dakota.
According to family members, the pilot and three passengers had been in Texas for business. The pilot's family reported that they had intended to leave earlier
in the day, on the day of the accident, but elected to delay, and subsequently left later than they had planned. The family stated that most likely, the flight was
going to stop at 9D0 to drop off one passenger before continuing to Gettysburg Municipal Airport (0D8), Gettysburg, South Dakota.
A fixed base operator employee at KHRX witnessed the pilot fuel the accident airplane at the self-serve fuel pump just prior to the accident flight. He reported
that the fuel batch report showed 82.59 gallons of fuel had been dispensed. The pilot commented to the employee that he was going to "top it off" as he had
"pushed his luck on the trip down." The pilot also discussed the weather conditions in South Dakota, noting that it was raining there. The pilot also added that
the only reason they were leaving was because one of the passengers was anxious to get home.
The pilot contacted the Fort Worth Lockheed Martin Contract Flight Service Station at 1711 when the airplane was 38 miles west of Borger, Texas, on a direct
flight to North Platte, Nebraska. The pilot requested and obtained an abbreviated weather briefing. During this briefing, winds aloft and weather advisories for
the reported route of flight were provided. The pilot also provided a pilot report for his position.
At 1812 the pilot sent a text stating that they were "Into KS aways" (sic). At 1923 he sent a text stating that they were "into NE". At 2054 he stated that they
were flying by Chamberlain, South Dakota.
Several witnesses in the area reported seeing an airplane fly over their homes the evening of the accident. The first witness, located near the shore of the
Missouri River, near Fort Thompson, South Dakota, reported seeing an airplane about 200 feet above the ground, flying to the northeast, about 2045. He stated
that the airplane was low and was moving quickly. The second witness, located a few miles southwest of the accident site, reported seeing an airplane flying at
a very low altitude, headed north, about 2115. Neither witness reported hearing problems with the engine.
According to the Federal Aviation Administration (FAA), the airplane was reported missing by a concerned family member when the airplane did not arrive in
Gettysburg, South Dakota, on the evening of April 27, 2014. The wreckage of the airplane was located by members of the Hyde County Fire Department and
the Hyde County Sheriff's department around 0330 on the morning of April 28, 2014. The pilot was not communicating with air traffic control at the time of the
accident and radar data for the accident flight was not available.
OTHER DAMAGE
Wind turbine tower #14, part of the South Dakota Wind Energy Center owned by NextEra Energy Resources, was damaged during the accident sequence. One
of the three blades was fragmented into several large pieces. One large piece remained partially attached to a more inboard section of the turbine blade. The
inboard piece of this same turbine blade remained attached at the hub to the nacelle. The outboard fragmented pieces of the wind turbine blade were located in
a radius surrounding the base of the wind turbine tower. The other two wind turbine blades exhibited impact damage along the leading edges and faces of the
blades.
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The pilot, age 30, held a commercial pilot certificate with airplane single engine land, multiengine land, and instrument ratings. He was issued a second class
airman medical certificate without limitations on January 19, 2014. The pilot was a professional agricultural pilot and had flown agricultural airplanes in the area
for several seasons.
The family provided investigators the pilot's flight logbook. The logbook covered a period between April 22, 2010, and April 20, 2014. He had logged no less
than 3,895.8 hours total time; 100.7 hours of which were in the make and model of the accident airplane and 95.1 hours of which were in the accident airplane.
This time included 76.2 hours at night, 1.1 hours of which had been recorded within the previous 90 days. The pilot was current for flight with passengers at
night. He successfully completed the requirements of a flight review on January 18, 2013. He successfully completed an instrument proficiency check in a
PA-32R on February 7, 2014.
According to the FAA, the pilot was familiar with the accident area. Specifically, the pilot was familiar with the wind turbine farm and had expressed his concern
about the wind turbine farm to the FAA Flight Standards District Office in Rapid City, South Dakota. The details of his concerns were not available.
The accident airplane, a Piper PA-32R-300 (serial number 32R-7680159), was manufactured in 1976. It was registered with the FAA on a standard
airworthiness certificate for normal operations. A Lycoming IO-540-K1G5D engine rated at 300 horsepower at 2,700 rpm powered the airplane. The engine was
equipped with a 2-blade Hartzell propeller. The airplane was equipped and certified for flight in instrument meteorological conditions.
The airplane was maintained under an annual inspection program. A review of the maintenance records indicated that an annual inspection had been
completed on April 17, 2013, at an airframe total time of 4,766 hours.
The closest official weather observation station was Pierre Regional Airport (KPIR), Pierre, South Dakota, located 35 miles west of the accident location. The
elevation of the weather observation station was 1,744 feet mean sea level (msl). The routine aviation weather report (METAR) for KPIR, issued at 2124,
reported wind from 010 degrees at 19 knots, visibility 10 miles, light rain, sky condition broken clouds at 1,000 feet, overcast at 1,600 feet, temperature 6
degrees Celsius (C), dew point temperature 5 degrees C, altimeter 29.37 inches, remarks ceiling variable between 800 and 1,200 feet.
The METAR issued at 2139 for KPIR reported wind from 070 degrees at 19 knots, visibility 4 miles, rain, mist, sky condition ceiling overcast clouds at 800 feet,
temperature 6 degrees C, dew point temperature 5 degrees C, altimeter 29.37 inches, remarks ceiling variable between 600 and 1,300 feet.
Huron Regional Airport (KHON) in Huron, South Dakota, was located 53 miles to the east of the accident site at an elevation of 1,289 feet. The METAR issued
at 2055 for KHON reported wind from 100 degrees at 20 knots, gusting to 27 knots, visibility 10 miles, sky condition ceiling overcast at 1,000 feet, temperature
9 degrees C, dew point temperature 7 degrees C, altimeter 29.36 inches, remarks peak wind of 29 knots from 090 degrees at 2015, rain began at 1956 and
ended at 2006.
The National Weather Service (NWS) Surface Analysis Chart for 2200 CDT depicted a low-pressure center in southern Nebraska, with an occluded front
extending into northeastern Kansas. A stationary front extended from northeastern Nebraska southeast through southern Iowa. Surface wind east of the
accident location was generally easterly, with surface wind to the west of the accident location generally northerly. Station models across the state of South
Dakota depicted overcast skies, with temperatures ranging from the high 30's Fahrenheit (F) to the mid-50's F. Rain and haze were depicted across the state.
A regional Next-Generation Radar (NEXRAD) mosaic obtained from the National Climatic Data Center (NCDC) for 2115 identified a large portion of South
Dakota under light to moderate values of reflectivity, including the region surrounding the accident site. WSR-88D Level II radar data obtained at 2114 from
Aberdeen, South Dakota, (KABR), depicted altitudes between 5,460 and 13,200 feet at the accident site. The KABR data identified an area of light reflectivity
coincident with the accident location approximately two minutes prior to the accident time.
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Advanced Very High Resolution Radiometer (AVHRR) data from the NOAA-16 satellite data were obtained from the National Oceanic and Atmospheric
Administration and identified cloudy conditions at or near the accident site. Cloud-top temperatures in the region varied between -53 degrees C and 6 degrees
C. The temperature of -53 degrees C corresponded to heights of approximately 35,000 feet. Due to a temperature inversion in the ABR sounding near 4,000
feet, the temperature of 6 degrees C may correspond to various cloud heights ranging from at or very near the surface to between 3,500 and 6,500 feet.
An Area Forecast that included South Dakota was issued at 2045 CDT. The portion of the Area Forecast directed toward the eastern two-thirds of South
Dakota forecasted for the accident time: ceiling overcast at 3,000 feet msl with cloud tops to flight level (FL)180, widely scattered light rain showers, and wind
from the east at 20 knots with gusts to 30 knots. Prior to the 2045 CDT Area Forecast, another Area Forecast that included South Dakota was issued at 1345
CDT. The portion of the Area Forecast directed toward the central and eastern portions of South Dakota forecasted for the accident time: ceiling overcast at
3,000 feet msl with clouds layered up to FL300, scattered thunderstorms with light rain, cumulonimbus cloud tops to FL400, wind from the southeast at 20
knots with gusts to 35 knots.
Airmen's Meteorological Information (AIRMET) SIERRA for IFR conditions was issued at 1959 CDT for a region that included the accident location. AIRMET
TANGO for moderate turbulence for altitudes below 15,000 feet was issued at 1545 CDT for a region that included the accident location. The AIRMET also
addressed strong surface winds for a region that did not include the accident location. AIRMET ZULU for moderate ice for altitudes between the freezing level
and FL200 was issued at 1545 CDT for a region that included the accident location.
There were no non-convective Significant Meteorological Information (SIGMET) advisories active for the accident location at the accident time. There were two
Convective SIGMETs issued for convection close to the accident location in the two hours prior to the accident time
According to the United States Naval Observatory, Astronomical Applications Department Sun and Moon Data, the sunset was recorded at 2037 and the end of
civil twilight was 2109. The moon rose at 0615 on the following day.
At the time of the accident the wind turbine tower #14 recorded the wind velocity at 9.7 meters per second or 21 miles per hour and the ambient temperature
was 7 degrees C.
The pilot logged on to the CSC DUAT System on April 26, 2014, at 2141:36 and requested a low altitude weather briefing quick path service. The pilot identified
the route of flight as a direct flight between KHRX and 0D8, at an altitude of 8,500 feet.
AIDS TO NAVIAGATION
The FAA Twin Cities Sectional Chart 87th edition, dated 9 January, 2014, through 26 June, 2014, depicted the city of Highmore, South Dakota, and the
Highmore Airport on the southern edge of the chart boundary. The city of Highmore and the airport were both within the same boundary box with a maximum
elevation figure of 24 or 2,400 feet msl. The maximum elevation figure immediately south of Highmore was 27 or 2,700 feet msl. An obstacle at an elevation of
276 feet above ground level (agl) and 2,180 feet msl was depicted immediately south of the city of Highmore. A wind farm was depicted south and east of Ree
Heights, South Dakota - this wind farm was at an elevation of 420 feet agl and 2,447 feet msl. The wind farm involved in this accident was not depicted on this
sectional chart.
The FAA Omaha Sectional Chart 89th edition, dated 6 February, 2014, through 24 July, 2014, depicted the city of Highmore, South Dakota, and the Highmore
Airport on the northern edge of the chart boundary. The city of Highmore and the airport were both within the same boundary box with a maximum elevation
figure of 24 or 2,400 feet msl. The maximum elevation figure immediately south of Highmore was 27 or 2,700 feet msl. A wind farm was depicted south and
east of Ree Heights, South Dakota - this wind farm was at an elevation of 420 feet agl and 2,447 feet msl and 420 feet agl and 2,500 feet msl.
A single obstruction was depicted on the chart about 7 miles south of the city of Highmore, just to the east of highway 57. The obstruction was at an elevation
of 215 feet agl and 2,335 feet msl. A group of obstructions was depicted on the chart about 9 miles south of the city of Highmore, just to the west of highway
57. The obstructions were at an elevation of 316 feet agl and 2,496 feet msl. The wind farm involved in this accident was not depicted on this sectional chart as
a wind farm.
According to the FAA, the 90th edition of the Omaha Sectional Chart, effective from 24 July, 2014, through 5 February, 2015, added the depiction of the
accident wind farm just south of the city of Highmore. This depicted the wind farm west and southwest of highway 57 at an elevation of 2,515 feet msl. In
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addition, an unlit obstruction at an elevation of 415 feet agl and 2,597 feet msl was depicted just south of the wind farm boundary.
There are no instrument approach procedures into 9D0. There are two RNAV (GPS) approaches, runway 13 and runway 31, into 0D8.
FLIGHT RECORDERS
The accident airplane was equipped with an Apollo GX-50 panel-mount 8-channel GPS receiver. The unit includes a waypoint database with information about
airports, VOR, NDB, en route intersections, and special use airspace. Up to 500 custom user-defined waypoints may be stored, as well. The GX-50 is a
TSO-C129a class unit capable of supporting IFR non-precision approach operations. Thirty flight plans composed of a linked list of waypoints may be defined
and stored. The real-time navigation display can be configured to show: latitude/longitude, bearing, distance to target, ground speed, track angle, desired track,
distance, and an internal course deviation indicator (CDI). The unit stores historical position information in volatile memory; however, by design there is no
method to download this information.
The unit was sent to the NTSB Vehicle Recorders Lab in Washington D.C. for download. Upon arrival at the Vehicle Recorders Laboratory, an exterior
examination revealed the unit had sustained significant structural damage. An internal inspection revealed most internal components, including the battery,
were dislodged. Since the internal battery was dislodged and the unit relied upon volatile memory to record information, no further recovery efforts were
attempted.
The accident scene was located in level, vegetated terrain, in the middle of a wind turbine farm, about 10 miles south of Highmore, South Dakota. The terrain
was vegetated with short and medium grass. The wreckage of the airplane was fragmented and scattered in a radius to the north, through to the west, and then
through the south, surrounding the base of wind turbine tower #14. The fragmented pieces of the fuselage, empennage, engine and propeller assembly, and
both wings were accounted for in the field of debris.
The autopsy was performed by the Sanford Health Pathology Clinic on April 29, 2014, as authorized by the Hyde County Coroner's office. The autopsy
concluded that the cause of death was multiple blunt force injuries and the report listed the specific injuries.
The FAA's Civil Aerospace Medical Institute (CAMI), Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological tests
on specimens that were collected during the autopsy (CAMI Reference #201400071001). Results were negative for all carbon monoxide and drugs. Testing of
the blood detected 11 mg/dL ethanol; however, none was detected in the muscle or liver. Tests for cyanide were not conducted.
TESTS AND RESEARCH
Wreckage Examination
The wreckage was recovered and relocated to a hangar in Greeley, Colorado, for further examination. The wreckage was examined by investigators from the
National Transportation Safety Board, Piper Aircraft, and Lycoming Engines.
The left wing separated from the fuselage and was fragmented. The fuel tanks were impact damaged and the left main landing gear separated from the wing
assembly. The aileron and the flap separated from the wing assembly and were impact damaged.
The right wing separated from the fuselage and was fragmented. The fuel tanks were impact damaged. The right main landing gear was extended and remained
attached to the right wing spar. The aileron and the flap separated from the wing assembly and were impact damaged.
The fuel selector valve was impact damaged. The position of the selector handle was at the left main fuel tank. Disassembly of the valve found the selector in
an intermediate position between off and the left main tank. The fuel screen was clear of debris.
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The instrument panel was fragmented and many of the instruments, radios, and gauges were destroyed. The ADI case and the directional gyro exhibited
signatures of rotational scoring. The tachometer exhibited a reading of 2,400 to 2,500 rpm. The altimeter was broken and the needles separated. The Kollsman
window was set at 29.27 inches. The airspeed indicator exhibited a reading of 235 miles per hour.
The pitot static system was impact damage and fragmented. The pitot tube and static port were clear and free of debris or mechanical blockage. Due to the
damage, the system could not be functionally tested.
The empennage separated from the fuselage and was impact damaged. The aft portion of the vertical stabilizer was impact damaged and remained partially
attached to the rudder at the hinge points. The stabilator was impact damaged and fragmented.
Flight control continuity to the ailerons, stabilator, and rudder could not be confirmed. The flight control cables were fractured in overload in multiple locations.
The position of the flaps and landing gear could not be determined due to impact damage.
The engine was impact damaged impeding examination and testing for functionality. The spark plugs exhibited worn out normal signatures when compared to
the Champion Aviation Check-A-Plug chart. The fuel injectors for the 1, 3, and 5 cylinders were clear of debris. The fuel injectors for the 2, 4, and 6 cylinders
were impact damaged. The oil pick-up screen was clear of debris. The fuel servo and fuel pump were impact damaged and could not be functionally tested.
The fuel flow divider was clear of debris. The vacuum pump case was bent and exhibited internal scoring consistent with operation at the time of the accident.
The propeller separated from the engine at the propeller flange. One blade exhibited S-bending, a curled tip, chord-wise scratches, and nicks and gouges along
the leading edge of the propeller blade. The second blade exhibited chord-wise scratches, nicks and gouges along the leading edge of the propeller blade, and
grey angular pain transfer near the tip of the propeller blade.
Wind Turbine Tower #14 Obstruction Light Power Supply, Flash Head, and Photocell Examination
The obstruction light, which included the power supply, flash head, and photocell (44812A), was removed from wind turbine tower #14 by an employee of ESI
at the request of the wind turbine company. All of the components were shipped to Hughey & Phillips for further examination.
During the examination the following observations were made:
The flash head gasket was broken into 5 pieces. The day lens was crazed and a screw was loose in flash head.
The photocell which was in the container is an aftermarket unit and not as supplied by Hughey & Phillips.
An aftermarket transformer was added to the power supply above the TB1 terminal block. This was not wired into the power supply and two wires hung
from the transformer.
The power supply was placed on test jig and the power supply and flash head were connected via a 7-wire power cable, 7 feet in length, provided by Hughey &
Phillips. When power was applied to the unit the flash head did not work - the red lamp attempted to flash and the white lamp did not flash.
The lower flash tube was black consistent with age/use
The power supply - capacitor C3 - was bulged at the top consistent with a bad capacitor
The capacitor was replaced and the red lamp functioned as designed. The white lamp did not function. The white flash tube was replaced with a new flash tube.
When it was in day mode the white light activated
When in night mode the red light activated
When in auto mode, light was applied to the photocell sensor and after 30 seconds it switched from night to day mode. When light was removed and the
sensor was covered to remove light, it switched back to night mode after 30 seconds.
The photocell was placed in a test chamber. When all light was removed, one light bulb illuminated. When 5 candelas was applied there was no change. The
candelas were increased incrementally to 30 with no change. When the candelas were increased to 50, the test chamber switched to night mode within a
minute or more.
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The flash rate of the unit was tested.
The red lamp tested at a rate of 25 flashed per minute - This is within the FAA specifications for the L-864 fixture, 20 to 40 flashes per minute.
The white lamp tested at a rate of 40 flashes per minute- This is within the FAA specifications for the L-865 fixture, 40 flashes per minute.
The alarm function tested as designed.
The entire system operated normally with basic replacement of the flashtube and capacitor. The system was not operational in its as removed state.
Wind Turbine
The wind turbine farm south of Highmore, South Dakota, was constructed in 2003. There are 27 towers in the entire farm oriented from east to west across
highway 57. It was reported to the NTSB, on scene, that each turbine tower is about 213 feet tall (from the ground to the center of the hub) and the blade length
is 100 feet long. Each tower is equipped with three blades and FAA approved lighting. The blades are constructed from carbon fiber.
On June 2, 2003, the FAA issued a Determination of No Hazard to Air Navigation, regarding the installment of wind turbine tower #14 near Highmore, South
Dakota. The document identified that the wind turbines would be 330 feet agl and 2,515 feet msl. A condition to the determination included that the structure be
marked and/or lighted in accordance with FAA Advisory Circular 70/7460-1K Change 1.
The wind turbine tower #14 was located to the west of highway 57, and was the 5th wind turbine tower in a string of wind turbine towers, oriented from east to
west. Wind turbine tower #14 was 0.3 miles to the west of the 4th wind turbine tower and 0.5 miles to the west of the 3rd wind turbine tower. The string of wind
turbine towers changed direction after wind turbine tower #14 and continued to the south and south west for about 2 additional miles with 13 additional wind
turbine towers in the string. The next closest wind turbine tower to #14 was 0.5 miles south.
The wind turbine tower #14 recorded an alert in the system when the airplane and the turbine blade collided and the turbine went offline. The impact was
recorded at 2116:33. The blades were pitched at -0.5 degrees and the nacelle was at 112 degrees yaw angle (not a compass heading, rather nacelle rotation).
There were no employees at the wind farm maintenance facility when the accident occurred. The NextEra control center in Juno Beach, Florida, received an
immediate alert when the collision occurred. The company response would have been to send an employee to the wind turbine the next morning to determine
why the turbine had gone offline.
Maintenance records for wind turbine tower #14, for 5 years prior to the accident, were submitted to the NTSB investigator in charge for review. These records
included major and minor inspection sheets for 2010 and 2011 in addition to work management records for general maintenance, repairs, and fault
troubleshooting that occurred between June 2010, and October of 2014 (after the accident). The major and minor inspection sheets for 2010 and 2011 indicated
that the FAA lighting was inspected and found to be "normal" or "OK." No other maintenance records were provided which illustrated maintenance that was
conducted or performed on the FAA lighting system between 2010 and the accident.
It was reported to the NTSB IIC that the light on tower #14 was not functioning at the time of the accident and had been inoperative for an undefined period.
The actual witness to the inoperative light did not return telephone calls in attempt to confirm or verify this observation.
FAA Lighting Requirements
The US Department of Transportation - FAA issued Advisory Circular AC 70/7460-1K Obstruction Marking and Lighting on February 1, 2007.
Section 23. Light Failure Notification states in part that ".conspicuity is achieved only when all recommended lights are working. Partial equipment outages
decrease the margin of safety. Any outage should be corrected as soon as possible. Failure of a steady burning side or intermediate light should be corrected
as soon as possible, but notification is not required. B. Any failure or malfunction that lasts more than thirty (3) minutes and affects a top light or flashing
obstruction light, regardless of its position, should be reported immediately to the appropriate flight service station (FSS) so a Notice to Airmen (NOTAM) can
be issued."
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Section 44. Inspection, Repair, and Maintenance states in part that "Lamps should be replaced after being operated for not more than 75 percent of their rated
life or immediately upon failure. Flashtubes in alight unit should be replaced immediately upon failure, when the peak effective intensity falls below specification
limits or when the fixture begins skipping flashes, or at the manufacturer's recommended intervals. Due to the effects of harsh environments, beacon lenses
should be visually inspected for ultraviolet damage, cracks, crazing, dirt, build up, etc., to insure that the certified light output has not deteriorated."
Section 47. Monitoring Obstruction Light stated in part that "Obstruction lighting systems should be closely monitored by visual or automatic means. It is
extremely important to visually inspect obstruction lighting in all operating intensities at least once every 24 hours on systems without automatic monitoring."
Chapter 13, Sections 130 through 134, addressed Marking and Lighting Wind Turbine Farms. Wind turbine farms are defined as "a wind turbine development
that contains more than three (3) turbines of heights over 200 feet above ground level." In addition, a linear configuration in a wind farm is "a line-like
arrangement. The line may be ragged in shape or be periodically broke, and may vary in size from just a few turbines up to 20 miles long."
Section 131. General Standards states in part that "Not all wind turbine units within an installation or farm need to be lighted." "Definition of the periphery of the
installation is essential; however, lighting of interior wind turbines is of lesser importance." "Obstruction lights within a group of wind turbines should have
unlighted separations or gaps of no more than « statute mile if the integrity of the group appearance is to be maintained."
Section 134. Lighting Standards states in part that "Obstruction lights should have unlighted separations or gaps of no more than « mile. Lights should flash
simultaneously. Should the synchronization of the lighting system fail, a lighting outage report should be made in accordance with paragraph 23 of this advisory
circular." Section c. Linear Turbine Configuration states in part "Place a light on each turbine positioned at each end of the line or string of turbines. Lights
should be no more than « statute mile, or 2,640 feet from the last lit turbine."
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03/01/2015 940 PST
Acft Mk/Mdl PIPER PA 46-310P
Regis# N9133G
Redmond, OR
Acft SN 4608111
Rpt Status: Prelim
Fatal
Eng Mk/Mdl CONT MOTOR TSIO-520 SER
Opr Name: MALSTROM ROBERT
0
Apt: Roberts Field Airport KRDM
Ser Inj
Opr dba:
0
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: STN
Events
1. Enroute-cruise - Loss of engine power (total)
Narrative
On March 1, 2015, at 0940 Pacific standard time, a Piper PA-46-310P, N9133G, executed a forced landing into Roberts Field Airport, Redmond, Oregon, after
a complete loss of engine power. The airplane was registered to, and operated by, the private pilot under the provisions of 14 Code of Federal Regulations, Part
91. The pilot was not injured, and the airplane sustained substantial damage to both wings. Visual meteorological conditions prevailed, and an instrument flight
plan had been filed. The flight originated from Oak Harbor, Washington.
The pilot reported that he was cruising at 23,000 feet mean sea level (msl) when he noticed the engine running a bit rough as he passed Portland, Oregon. He
noticed that the number 5 exhaust gas temperature (egt) was higher than normal. The pilot cycled the magnetos and noticed that the engine ran rougher than
normal when the left magneto was selected. The engine smoothed out when he enriched the mixture. He continued to monitor the engine and adjusting the
mixture. About 30 minutes later engine power completely dropped off. The pilot diverted to Redmond, and performed a forced landing into the airport infield.
The landing resulted in a collapsed nose landing gear, and wing spar damage at both main landing gear mounts.
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07/16/2011 1830 PDT Regis# N5532P
Lopez, WA
Apt: Windsock Airport 4WA4
Acft Mk/Mdl PIPER PA-24-250
Acft SN 24-596
Eng Mk/Mdl LYCOMING O-540-A1D5
Acft TT
Fatal
Opr Name: PERSON TIM I
Opr dba:
6200
0
Ser Inj
0
Aircraft Fire: NONE
Events
1. Enroute-cruise - Loss of engine power (partial)
Narrative
On July 16, 2011, at 1830 Pacific daylight time, a Piper PA-24-250, N5532P, experienced a loss of engine power during cruise flight. The pilot subsequently
made a forced landing to a private grass strip near Lopez, Washington. The owner/pilot operated the airplane under the provisions of 14 Code of Federal
Regulations Part 91 as a personal cross-country flight. The commercial pilot, the sole occupant, was not injured. During the landing roll, the left wing was
substantially damaged when it struck a fence post. Visual meteorological conditions prevailed for the flight that departed Roche Harbor Airport (WA09), Roche
Harbor, Washington, at 1815. The flight was destined for Frontier Airpark (WN53), Lake Stevens, Washington. No flight plan had been filed.
The pilot reported that the airplane was in cruise flight about 2,000 feet near Spencer Island. He heard a loud bang, felt an extreme vibration, had smoke in the
cockpit, and oil covered the windshield. He reduced engine power to idle, opened the side vent window, and was able to regain visibility. He chose the closest
landing strip, and landed the airplane. On the landing rollout, the pilot stated that the grass strip was shorter than what he would need to bring the airplane to a
stop and the runway surface was wet. He intentionally placed the airplane in a "ground slide," and prior to coming to a stop, the left wing struck a fence post.
During the post-accident inspection of the engine, the pilot observed a crack in the engine block near the rear cylinder on the pilot's side. No further
examination was accomplished.
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03/29/2015 940 EDT
Regis# N32396
Orange, VA
Acft SN 28-7525060
Rpt Status: Prelim
Eng Mk/Mdl LYCOMING O-320 SERIES
Acft TT
Fatal
Opr Name: SKYLINE AVIATION SERVICES
Opr dba:
5156
1
Apt: Orange County Airport OMH
Ser Inj
0
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: STN
Events
1. Initial climb - Aerodynamic stall/spin
Narrative
On March 29, 2015, about 0940 eastern daylight time, a Piper PA28-140, N32396, impacted terrain after takeoff from Orange County Airport (OMH), Orange,
Virginia. The student pilot was fatally injured. Visual meteorological conditions prevailed, and no flight plan was filed for the flight, which was destined for
Farmville Regional Airport (FVX), Farmville, Virginia. The instructional flight was conducted under the provisions of Title 14 Code of Federal Regulations Part
91.
The owner of the flight school that operated the airplane stated that the student was departing on his first solo cross-country flight when the accident occurred.
After reviewing his preflight planning and assisting him in a preflight inspection of the airplane and engine run-up check, she observed as the pilot taxied to the
terminal to obtain fuel. The pilot then performed a second engine run-up and departed from runway 08. She stated that the takeoff appeared normal, but that
the pilot appeared to initiate a left turn to the crosswind leg of the traffic pattern earlier than was customary. As the airplane turned left, she watched as its nose
pitched upward before it rolled sharply left and descended to ground contact.
Two pilot-rated witnesses located on the north side of the airport observed the airplane during the takeoff. They remarked to each other that it appeared
"abnormally slow" and stated that it did not seem to be gaining altitude. Both individuals also reported viewing a thin trail of "smoke" or "brown exhaust" from
the airplane's engine. The witnesses observed the airplane make a sharp left turn and descend steeply to ground contact. One of the witnesses reported that
the winds were light and variable from the north and east.
The pilot held a student pilot certificate and Federal Aviation Administration (FAA) third-class medical certificate, which was issued on January 20, 2015.
Review of the pilot's logbook revealed that he had accumulated 30.6 total hours of flight experience, of which about 18 hours were in the accident airplane, and
2.7 hours were solo.
The 0935 weather observation at OMH included wind from 040 degrees at 3 knots, 10 miles visibility, clear skies, temperature 0 degrees C, dew point -12
degrees C, and an altimeter setting of 30.41 inches of mercury.
The airplane came to rest upright in a field located about 1,330 feet northeast of the departure end of runway 08, with the wreckage oriented on a heading of
about 170 degrees magnetic. The initial impact point was identified by a ground scar about 30 feet south of the main wreckage that contained pieces of the left
wing navigation light. Areas of disturbed soil extended north from the initial impact point about 15 feet toward a large impact crater about 6 feet in length and 3
feet in width, which contained pieces of the propeller spinner and ground scars consistent with propeller contact.
The propeller remained attached to the crankshaft flange and one blade exhibited slight forward bending. Both blades displayed chordwise scratching and
leading edge gouging. The engine remained attached to the fuselage by its bottom mounts. The fuselage displayed significant aft crushing from the engine
firewall to the rear cabin seats, and was displaced to the left just aft of the baggage area. Both left and right wings displayed significant aft crushing of their
leading edges. The left wing was separated from the fuselage at its root and the fuel tank was breached. Residual fuel was found inside, and the fuel tank cap
was in place and secure. The left aileron remained attached at its hinge points. Control continuity was established from the aileron to the cockpit area through
cable breaks at the wing root that displayed signatures consistent with overstress failure. The right wing remained attached to the fuselage at its root. The
outboard approximate 4 feet was bent upward about 45 degrees. The right fuel tank was breached and leaking fuel; the right fuel tank cap was in place and
secure. The right aileron remained attached at its hinge points and control continuity was established from the aileron to the cockpit area. The wing flaps were
fully retracted. The empennage was intact and displayed minor impact damage. The rudder remained attached to the vertical stabilizer at its hinge points, and
the stabilator remained attached at its mounting blocks. Rudder and stabilator control continuity was established to the cockpit area. The windscreen and left
cabin window were destroyed upon impact and pieces of each were distributed along the wreckage path and around the main wreckage. Examination of the
wings, empennage, and windscreen pieces did not reveal any evidence of a bird strike.
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The engine crankshaft was rotated by hand at the propeller hub and continuity of the valve and powertrains was confirmed. The spark plugs were removed and
displayed black carbon fouling. Thumb compression was obtained on all cylinders, and borescope examination of the cylinders revealed no anomalies. The
carburetor inlet screen was absent of debris. The carburetor was removed and the bowl was opened. The floats were intact, and the bowl contained fuel
consistent with the color and odor of 100 low lead aviation fuel and was absent of contamination. The magnetos remained secured to their mounts, and were
removed and actuated by hand. Each magneto produced spark at all of its terminal leads.
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12/26/2013 530 EST
Acft Mk/Mdl PIPER PA-30
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
Summary
Before the flight, the pilot obtained weather information for an airport near the departure airport and for an airport about 275 miles south along his route of flight.
He did not file a flight plan, did not receive any other services for the accident flight, and departed in night visual meteorological conditions. According to GPS
and air traffic control data, the airplane was flying on a southwesterly heading before it turned right. It subsequently turned left and then right before it entered a
descending left turn and impacted terrain. Examinations of the airframe and engines revealed no preimpact mechanical malfunctions that would have precluded
normal operation. Further, there was no evidence of a medical impairment that would have affected the pilot's performance. A review of the plot's logbooks
revealed no entries for night or instrument flight in the year before the accident.
A National Weather Service observation from about 15 miles southwest of the accident site showed rapidly changing conditions with a band of snow moving
across the region at the time of the accident. In addition, the next observation showed a lowering ceiling that was overcast to broken from 3,200 to 2,800 ft
above ground level; snow started falling about 26 minutes after the accident. Considering the weather conditions around the time of the accident, it is likely that
the pilot inadvertently encountered instrument meteorological conditions in light snow with no visible surface lights and, as a result, had to transition to relying
solely on the instruments. Given these conditions, the pilot's limited instrument and night experience, and the pilot's maneuvering, it is likely that he
experienced spatial disorientation and subsequently entered a descending left turn and lost control of the airplane.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The noninstrument-rated pilot's
spatial disorientation after inadvertently encountering instrument meteorological conditions at night and his subsequent loss of airplane control.
Events
1. Enroute - Loss of control in flight
2. Enroute - Aircraft structural failure
1. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Lateral/bank control-Not attained/maintained - C
3. Personnel issues-Experience/knowledge-Experience/qualifications-Qualification/certification-Pilot - C
4. Personnel issues-Psychological-Perception/orientation/illusion-Spatial disorientation-Pilot - C
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.
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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
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.
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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
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."
Forensic toxicology was performed on specimens from the pilot by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The
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
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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
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 Mk/Mdl PIPER PA-30
Acft SN 30-785
Acft Dmg: DESTROYED
Eng Mk/Mdl LYCOMING IO-320 SERIES
Acft TT
Fatal
Opr Name: ALBERT D. WHITWORTH
Opr dba:
1370
3
Ser Inj
0
Aircraft Fire: NONE
Summary
According to the airport manager, who was also a flight instructor, the student pilot had completed 10 hours of dual instruction in a single-engine airplane and
completed three supervised solos. After the student pilot's third supervised solo, he discontinued his training with the airport manager and enrolled in a flight
program at a community college. The airport manager did not know if the student pilot continued with his training. A review of the student pilot's records
revealed that he had no entries or endorsements related to multiengine, night, or instrument flights.
Instrument meteorological conditions existed on the night of the accident. An airport security video showed the accident airplane taxiing to the active runway.
Shortly thereafter, the airplane's strobe lights can be seen reflecting off of the runway and then illuminating in the low clouds; the strobe lights then disappear
from the camera's view. A witness in the area reported hearing an airplane flying low and then the sound of a loud crash. The witness subsequently contacted
the local authorities, and the airplane was located 1 mile from the airport in a heavily wooded area. The airplane's owner reported that he had not given the
student pilot permission to use the airplane. An examination of the airplane did not reveal any anomalies that would have precluded normal operation.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The student pilot's poor
judgment to take a multiengine airplane for which he did not have experience or permission to operate and depart into night instrument meteorological
conditions, which resulted in a loss of airplane control and impact with terrain.
Events
2. Uncontrolled descent - Miscellaneous/other
1. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-(general)-Not attained/maintained - C
2. Personnel issues-Action/decision-Info processing/decision-Decision making/judgment-Student/instructed pilot - C
3. Personnel issues-Experience/knowledge-Experience/qualifications-Qualification/certification-Student/instructed pilot - C
4. Personnel issues-Miscellaneous-Intentional act-Stolen/unauthorized-Student/instructed pilot - C
5. Personnel issues-Task performance-Use of equip/info-Aircraft control-Student/instructed pilot - C
6. Environmental issues-Conditions/weather/phenomena-Ceiling/visibility/precip-Low ceiling-Effect on personnel - C
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
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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
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.
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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.
Forensic toxicology was performed on specimens from the pilot by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The
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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10/17/2013 1230 EDT Regis# N555GK
Franklin, NC
Apt: Macon County Airport 1A5
Acft SN 31-7405456
Eng Mk/Mdl LYCOMING TI0-540 SER
Acft TT
Fatal
Opr Name: LUNSFORD AIR CONSULTING INC
Opr dba:
7574
0
Ser Inj
0
Aircraft Fire: NONE
Events
3. Landing-landing roll - Sys/Comp malf/fail (non-power)
Narrative
HISTORY OF FLIGHT
On October 17, 2013 about 1230 eastern daylight time, a Piper PA-31-350, N555GK, operated by a private individual, was substantially damaged while landing
at Macon County Airport (1A5) Franklin, North Carolina. The airline transport pilot and seven passengers were not injured. The flight was conducted under the
provisions of 14 Code of Federal Regulations Part 91. Instrument meteorological conditions prevailed and an instrument flight plan was filed for the flight that
departed Flagler County Airport (XFL) Palm Coast, Florida at 1100.
The pilot stated that during the pre-flight inspection of the airplane, both the left and right brake reservoirs were checked for proper servicing and were found to
be ready for flight. While landing at 1A5, the pilot selected the gear to the "DOWN" position and pumped the brakes to confirm they were functioning normally
before landing. As the airplane touched down, he applied the brakes, but the "left brake went to the floor." The pilot utilized left rudder and minimal usage of the
right brake to stay on runway centerline. At 20 knots, the right brake "locked up", the airplane departed the right side of the runway, and collided with a ditch.
The hobbs meter showed 7,754 hours at the time of the accident.
The Federal Aviation Administration did not conduct an on-scene examination of the airplane. Photographs taken by the 1A5 airport manager revealed
substantial damage to the left winglet and to the left wing spar. The airport manager reported a pool of red fluid on the ground beneath the left main landing gear
that was consistent with aviation brake fluid, and that the left wheel brake reservoir was empty. There was also red fluid seeping from the "B" nut fitting that
tightens the hydraulic brake line to the brake caliper.
A 10 year historical review of the FAA Service Difficulty Report database and Piper service bulletins did not reveal any brake line failures or modifications.
A section of the left brake line with the "B" nut and ferrule fitting attached was removed and sent to the National Transportation Safety Board Materials
Laboratory for further examination.
FAA information indicated that the pilot held an airline transport certificate with ratings for multi-engine land, single engine sea. The pilot also held a flight
instructor certificate with ratings for airplane multi-engine, instrument airplane, and instrument helicopter. The pilot reported a total flight experience of 30,000
hours, including 3,000 hours in the accident airplane make and model. His most recent flight review was completed June 26, 2013, and his most recent FAA
second-class medical certificate was issued on September 18, 2013.
The twin-engine, retractable-gear, low wing, all metal multi-engine powered airplane, serial number 31-7405456, was manufactured in 1974. It was powered by
two Lycoming LTI0-540, 350-horsepower engines. A review of the aircraft maintenance records revealed the airplane's most recent annual inspection was
completed on July 9, 2013, at an aircraft total time of 7552.2 hours, which was 22 hours prior to the accident.
According to an airframe logbook entry dated July 9, 2013, "placed aircraft on jacks and performed landing gear functional and emergency operational checks.
Lubricated landing gear system."
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The 1235 automated weather observation at 1A5 included winds calm, scattered clouds 800 feet, broken clouds 1700 feet, overcast clouds 3800 feet, visibility
7 statute miles, temperature 17 degrees C, dew point 16 degrees C, and an altimeter setting of 29.98 inches of mercury.
AIRPORT INFORMATION
The airport was equipped with a single paved runway, designated 07/25. The runway was asphalt, and measured 75 feet by 5,000 feet. Airport elevation was
2,034 feet above mean sea level.
Brake System
The airplane was equipped with a hydraulic fluid braking system that included two independent wheel brakes actuated by two separate brake master cylinders,
one each for the left and right brake. A hydraulic fluid reservoir, separate from the main hydraulic system, supplied fluid to each cylinder. From the cylinders,
hydraulic fluid was routed through hoses and lines to a parking brake valve, located in the forward cabin, through the cabin and wings and to the left and right
main landing gear brake assemblies. The brake lines were composed of type 304 stainless steel and attached to a brake caliper via an aluminum swaged
sleeve that was compressed behind a nut. Depression of the brake pedal actuated a piston rod in the master cylinder, which applied hydraulic pressure to the
brake caliper pistons. Release of the pedal permitted the piston rod to be back-driven by a spring, which in turn released brake pressure at the wheel.
Inspection and Maintenance Information
According to the airplane's mechanic, he followed the PA-31-350 100 hour phase inspection checklist during the airplane's last annual inspection. He performed
a visual inspection for leakage and corrosion and physically checked the tightness of the "B" nut at the brake caliper.
The airplane owner reported that the landing gear was cleaned about twice a month with a degreaser. The landing gear was then rinsed with soap and water
after each chemical application.
Review of the make and model airplane preflight inspection section of the pilot's operating handbook stated, "Left Wing - (12) Landing gear - condition, strut
inflation, micro switches, tires, brakes, gear door."
Materials Laboratory
The left brake line and "B" nut were sent to the NTSB Materials Laboratory for examination. Metallurgical examination revealed fatigue striations at the end of
the brake line consistent with fatigue cracking. The swaged sleeve exhibited intergranular cracking consistent with exfoliation corrosion. Chemical examination
of the brake line tube revealed that it was consistent with manufacturer's specifications. The composition of the aluminum 2024 swaged sleeve was also
consistent with manufacturer's specification.
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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
Eng Mk/Mdl LYCOMING TI0-540 SER
Acft TT
Fatal
Opr Name: FLEBO AIR LLC
Opr dba:
5918
2
Ser Inj
0
Aircraft Fire: GRD
Summary
A review of air traffic control information revealed that, during the cross-county flight, the pilot requested clearance for a precautionary landing at a nearby
airport due to a low oil pressure indication. Shortly after the flight was cleared for landing, the pilot reported that the engine had lost total power. The pilot
advised the air traffic controller that he could not make it to the airport and requested to land at a military base that was closer to his current position. The pilot
was cleared to land at the military base; however, he never established radio contact with the military base tower. The airplane crashed about 0.8 mile
northeast of the base in a heavily wooded swamp, and a postcrash fire ensued.
An examination of the engine revealed that the crankcase was fractured in the areas of the Nos. 4, 5, and 6 cylinders, that the camshaft was fractured, and that
the Nos. 4, 5, and 6 connecting rods were separated from the crankshaft. The Nos. 1 and 2 connecting rod bearings and the Nos. 2 and 3 main bearings
exhibited wiping, scoring, and extrusion signatures consistent with oil starvation. Although review of maintenance records revealed that Federal Aviation
Administration airworthiness directives for the replacement of the oil cooler hose and the oil filter converter plate gasket were not accomplished, extensive
postcrash fire and heat damage to the engine components precluded a determination of the cause of the oil starvation.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: A total loss of engine power due
to oil starvation for reasons that could not be determined due to extensive postcrash fire and heat damage to the engine components.
Events
1. Emergency descent - Powerplant sys/comp malf/fail
2. Emergency descent - Loss of engine power (total)
3. Emergency descent - Collision with terr/obj (non-CFIT)
1. Aircraft-Aircraft power plant-Eng oil sys (airframe furnish)-Pressure-Malfunction - C
2. Aircraft-Aircraft power plant-Engine (reciprocating)-Recip eng oil sys-Failure - C
3. Environmental issues-Physical environment-Terrain-Rough terrain-Contributed to outcome
4. Aircraft-Aircraft power plant-Engine (reciprocating)-Recip eng oil sys-Not serviced/maintained
5. Aircraft-Fluids/misc hardware-Fluids-Oil-Fluid level - C
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)
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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,
temperature 30 degrees Celsius (C), dew point 17 degrees C, and altimeter setting 30.12 inches of mercury.
WRECKAGE INFORMATION
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
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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
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.
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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
Summary
A witness familiar with the pilot reported that the accident flight was the pilot's second flightÿto the airport that day to transport ceramic tiles to that location.
One witness 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 witnesses observed the airplane having difficulty climbing before it impacted water in a left-wing-low attitude. Based on the witness statements, the
pilot was likely performing a go-around maneuver before the accident, and the airplane entered an aerodynamic stall. The airplane came to rest on its left side
in about 8 ft of water and 200 yards from the departure end of the intended runway. Several witnesses reported hearing the engine operating with no hesitations
noted, and postrecovery examination revealed no mechanical malfunctions or abnormalities of the airframe or engine that would have precluded normal
operation.
During the examination, 666 lbs of ceramic tiles were found unsecured in the cargo compartment; this exceeded the cargo compartment weight limit by 57 lbs
and would have degraded the airplane's climb performance and increased its stall speed. The investigation could not determine the actual distribution of the
unsecured tiles in the cargo compartment before the accident, so postaccident weight and balance calculations were performed for several tile distribution
scenarios. The calculations revealed that, with a relatively even distribution or with the tiles in the forward position of the cargo compartment, the center of
gravity (CG) would have been within the CG envelope limits; with the tiles in the forward position, the CG would have been near its forward limit. However, with
the tiles in the aft position, the CG could have exceeded the aft CG limit by as much as about 4 inches. Based on the evidence, it is likely that, during the
approach to land, the unsecured tiles began to slide forward, which would have made the airplane's nose feel heavy and might have led to the pilot's decision to
go around. However, when the pilot applied power and began to pitch the airplane's nose up during the go-around, it is likely that the unsecured tiles slid aft,
which resulted in the CG exceeding its aft limit, the airplane's nose pitching up further, and the pilot's pitch control authority decreasing. These conditions
resulted in the airplane exceeding its critical angle-of-attack, experiencing an aerodynamic stall, and colliding with water. Although pilots operating under 14
Code of Federal Regulations (CFR) Part 91 are not required to conduct preflight weight and balance calculations, 14 CFR 91.9 does require the
pilot-in-command to comply with the operating limits, including weight and balance, in the approved airplane flight manual, which provides pilots weight and
balance computations, charts, and graphs.
Although toxicology testing of the pilot revealed ethanol in both the liver and muscle specimens, the variation in the amount of ethanol in the tissue specimens
suggests that most, and perhaps all, of the ethanol came from sources other than ingestion. Therefore, it is very unlikely that the pilot was impaired by ethanol
at the time of the accident. Further, no evidence for medical impairment or incapacitation was found.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's failure to secure the
cargo in the cargo compartment, which resulted in a weight shift that led to the center of gravity exceeding its aft limit during a go-around attempt and a
subsequent aerodynamic stall. Also causal to the accident were the pilot's inadequate preflight inspection and his loading the airplane beyond the cargo
compartment weight limit.
Events
1. Prior to flight - Aircraft loading event
2. Approach-VFR pattern final - Abrupt maneuver
3. Approach-VFR go-around - Collision with terr/obj (non-CFIT)
1. Aircraft-Aircraft oper/perf/capability-Aircraft capability-CG/weight distribution-Capability exceeded - C
2. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Pitch control-Capability exceeded - C
3. Personnel issues-Task performance-Planning/preparation-Weight/balance calculations-Pilot - C
4. Personnel issues-Action/decision-Info processing/decision-Decision making/judgment-Pilot - C
5. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Descent/approach/glide path-Not attained/maintained - C
6. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Airspeed-Not attained/maintained - C
7. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Angle of attack-Not attained/maintained - C
8. Personnel issues-Task performance-Inspection-Preflight inspection-Pilot - C
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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
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.
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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
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
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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.
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
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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
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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01/28/2014 1245 EST Regis# N16389
West Palm Beach, FL
Apt: Palm Beach Intl PBI
Acft SN 34-7350138
Eng Mk/Mdl LYCOMING LIO-360-C1E6
Acft TT
Fatal
Opr Name: RICHARD ROBERTS
Opr dba:
6617
0
Ser Inj
0
Aircraft Fire: NONE
Events
2. Landing-landing roll - Landing gear collapse
Narrative
On January 28, 2014, at 1245 eastern standard time, a Piper PA-34-200, N16389, experienced a nose landing gear collapse on landing roll at Palm Beach
International Airport (KPBI), West Palm Beach, Florida. The airplane sustained substantial damage to the fuselage. The certificated private pilot and passenger
were not injured. The airplane was registered to and operated by a private owner, under the provisions of Title 14 Code of Federal Regulations Part 91, as a
personal flight. Visual meteorological conditions prevailed and a defense visual flight rules flight plan was filed for the flight that originated from Marsh Harbour
Airport (MYAM), Marsh Harbour, Bahamas, about 1130.
During the approach, the pilot noted that the nose landing gear indication light was not illuminated. He aborted the landing and elected to fly by the air traffic
control tower in order to check the position of the landing gear. An air traffic controller confirmed that the landing gear appeared to be down. The airplane was
cleared to land; during the landing roll, the nose landing gear collapsed, and the airplane came to rest on the runway. The pilot and passenger were not injured
and both egressed the airplane without incident.
A postaccident examination of the airplane revealed substantial damage to the fuselage. Both the left and right side of the fuselage exhibited buckled skin. In
addition, the nose section of the airplane exhibited crush damage. The tachometer indicated 6617.32 hours.
The pilot held a private pilot certificate for airplane single-engine and multiengine land. In addition, he held a third-class medical certificate issued on August 13,
2014. Despite several attempts, the pilot would not return phone calls nor did he return Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1.
According to Federal Aviation Administration records, the airplane was manufactured in 1973. It was equipped with two Lycoming, IO-360 series, engines. The
most recent annual inspection was performed on January 20, 2012, and at that time the left tachometer read 6383.0 hours and the right tachometer read
6359.0 hours.
The airplane was equipped with retractable landing gear that utilized hydraulic pressure and gravitational forces to hold the landing gear in the desired position.
According to Section 7 of the Pilot's Operating Handbook, the landing gear description stated that "during the gear extensions, once the nose gear has started
toward the down position, the airstream pushes against it and assists in moving it to the downlocked position. After the gears are down and the downlock hooks
engage, springs maintain force on each hook to keep it locked until it is released by the hydraulic pressure."
A Federal Aviation Administration inspector performed a postaccident examination of the nose landing gear. The examination revealed that there was a
hydraulic leak above the nose landing gear actuator and the upper and lower nose landing gear drag links were not secured in accordance with the
maintenance manual. The inspector stated that "lubrication and wear measurements of the [service bulletin] and [airworthiness directive] have not been
accomplished for some time." In addition, the inspector noted that the nose landing gear microswitch "appear[ed] to have been recently replaced," however, this
was not noted in the airplane maintenance logbooks.
The FAA inspector interviewed the mechanic who had performed the most recent two annual inspections on the airplane and the mechanic stated that "he
hadn't seen the aircraft for two years and was unsuccessful in his attempts to contact [the pilot]."
Beginning in November 2004, the manufacturer issued a mandatory service bulletin (SB) 1123, with subsequent revisions A and B, which introduced the
revised inspection requirements and identified those parts which had undergone design modification improvements. Included in the service bulletin were
revisions and refinements of the rigging procedures pertaining to the Nose Gear installation. Inspections were to take place at the next regularly scheduled
maintenance event, not to exceed 50 hours of time in service, and thereafter on a recurring basis, at a frequency interval not to exceed 100 hours. In addition,
an inspection of the nose landing gear actuator mounting bracket for cracks, elongation of the holes where the retraction link attaches, and loose mounting
rivets, as well as lubricating the nose landing gear assembly was to be performed on a recurring basis, at a frequency interval not to exceed 50 hours.
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An Airworthiness Directive (AD) 2005-13-16 was issued by the FAA on August 8, 2005, to detect, correct, and prevent failure in certain components of the nose
landing gear, lack of cleanliness of the nose landing gear due to inadequate maintenance, or lack of lubricant in the nose landing gear or nose landing gear
components. According to the FAA inspector that examined the wreckage, the AD was applicable to the accident airplane, and could have been complied with
by inspecting the nose landing gear every 100 hours per the Piper Aircraft Mandatory Service Bulletin No. 1123B.
Review of the airplane's maintenance log entries revealed that the AD had originally been complied with and that the most recent entry, which was also the
most recent annual inspection, dated January 20, 2012, stated that AD 2005-16-14 was complied with as well and "no defects noted."
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02/15/2015 1230 PST Regis# N7928W
Garfield, WA
Apt: N/a
Acft Mk/Mdl PIPER PA28 - 180-180
Acft SN 28-1969
Acft TT
Fatal
Opr Name: PETER PUPATOR
Opr dba:
4830
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Summary
The pilot reported that while conducting a low-level sightseeing flight, he inadvertently collided with an unmarked power line with the airplane's left wing. The
pilot subsequently made a precautionary landing in a field without further incident. A postaccident examination of the airplane revealed substantial damage to
the left wing. The pilot reported no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot did not maintain
clearance from a power line while maneuvering at a low altitude.
Events
1. Maneuvering-low-alt flying - Collision with terr/obj (non-CFIT)
2. Maneuvering-low-alt flying - Low altitude operation/event
1. Personnel issues-Psychological-Attention/monitoring-Monitoring environment-Pilot - C
2. Environmental issues-Physical environment-Object/animal/substance-Wire-Effect on operation
Narrative
The pilot reported that while conducting a low-level sightseeing flight, he inadvertently collided with an unmarked power line with the airplane's left wing. The
pilot subsequently made a precautionary landing in a field without further incident. A postaccident examination of the airplane revealed substantial damage to
the left wing. The pilot reported no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation.
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Accident Rpt# WPR15FA135
03/26/2015 1230
Regis# CGAUS
Acft Mk/Mdl PIPER PA32R - 301-301
Opr Name: DAVID CHARRON
Townsend, MT
Rpt Status: Prelim
Fatal
1
Ser Inj
Opr dba:
1
Prob Caus: Pending
Aircraft Fire: UNK
Events
2. Enroute-cruise - Controlled flight into terr/obj (CFIT)
Narrative
On March 26, 2015, about 1230 mountain daylight time, a Piper PA-32R-301 airplane, Canadian registered C-GAUS, collided with mountainous terrain about 16
miles Northeast of Townsend, Montana. The private pilot was fatally injured and the passenger was seriously injured. The airplane sustained substantial
damage to both wings, the empennage and fuselage. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal
Regulations Part 91 as a cross-country flight. Visual meteorological conditions prevailed for the flight, and a flight plan was not filed. The flight departed about
1200 from Great Falls International Airport, Great Falls, Montana, and had a destination of Scottsdale Airport, Scottsdale, Arizona.
According to Air Traffic Control (ATC), at the Helena Regional Airport (HLN), Helena, Montana, the accident airplane was receiving service from the non-radar
approach control facility at about 1220. The pilot reported that he was reversing his course due to clouds in the area and shortly after communication was lost.
The National Transportation Safety Board (NTSB), investigator-in-charge (IIC) interviewed the passenger who stated that when the airplane entered into the
clouds the pilot communicated to ATC that he was turning around. She further stated that during the right turn to reverse course, the airplane subsequently
collided with terrain.
The NTSB IIC examined the accident site and reported that the majority of the airplane came to rest at the end of a debris field that was about 300 feet in
length. The debris field was in heavily wooded and snow covered terrain. Both wings had separated from the fuselage, with additional wreckage strewn
throughout the debris field. The forward fuselage partially separated near the cabin area, revealing the forward cabin seats. The fuselage came to rest on its
right side.
The nearest weather reporting station was HLN, about 37 miles west of the accident site. According to recorded information, at 1053, the wind was from the
west at 22 knots, gusting to 29 knots. At 1053 and at 1153 the wind was from the west at 18 knots. The overcast conditions were 4,800 and 5,500 feet
respectively.
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09/28/2014 1152 EDT Regis# N3740A
Lebanon, CT
Acft Mk/Mdl QUICKSILVER EIPPER ACFT INC GT 400 Acft SN GT 2801051
Eng Mk/Mdl ROTAX 503
Fatal
Opr Name: VESPIA ANTHONY J
0
Ser Inj
1
Opr dba:
Aircraft Fire: NONE
AW Cert: UNK
Events
1. Initial climb - Controlled flight into terr/obj (CFIT)
Narrative
On September 28, 2014, at 1152 eastern daylight time, a Quicksilver Eipper GT 400, N3740A, was substantially damaged when it impacted trees while taking
off from a private airstrip in Lebanon, Connecticut. The non-certificated pilot was seriously injured. Visual meteorological conditions prevailed, and no flight plan
had been filed for the flight to Richmond Airport (08R), West Kingston, Rhode Island, under the provisions of 14 Code of Federal Regulations Part 91.
According to a witness, she was sitting in her living room when she heard what sounded like an airplane taking off from the airstrip located beyond the trees in
her back yard. It sounded very loud and low, so she ran to a window at the back of her house to see if it would clear the trees when she heard it hit the trees
and then crash. She heard the engine still running for a few minutes after the crash and then it stopped.
The pilot was interviewed by a Federal Aviation Administration (FAA) inspector while recovering in the hospital. According to the inspector, the pilot had flown
the airplane from his home airport [08R] to the uncontrolled, private airstrip. It had been about 8 years since he had last flown there, and the pilot was unaware
that the airstrip had been shortened by about 200 feet. The pilot did not speak to anyone and stayed there about an hour. When he decided to depart, he
configured the airplane with 10-degrees flaps, and departed to the [north]west. In an attempt to clear trees beyond the end of the runway, he pulled back on the
control stick and stalled the airplane into those trees.
In further correspondence with the NTSB, the pilot stated that he only used about half of the runway to take off. About 8 to 10 feet in the air, the pilot thought
the airplane would clear trees at the end of the runway, and he continued the climb. The nose landing gear cleared the trees, but the main landing gear caught
the top of a tree. The airplane then turned to the right, stalled, and descended through the trees to the ground.
Winds, recorded at a nearby airport at the time of the accident, were from 340 degrees true at 8, gusting 18 knots. Estimated dimensions of the airstrip from a
Google Earth view were about 1,050 feet by 40 feet, oriented 290/110 degrees true.
The airplane was originally operated under Federal Air Regulations Part 103 for ultralight aircraft. The airplane was registered in 2007, but that registration
expired in 2012. The pilot did not possess a pilot certificate, but indicated that he had flown an estimated 2,500 hours in ultralights with about 500 hours in
make and model.
The pilot did not report any preexisting mechanical anomalies that would have precluded normal airplane operation.
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11/03/2013 1230 CST Regis# N981PA
Acft Mk/Mdl RAYTHEON AIRCRAFT COMPANY A36
Acft SN E-3599
Eng Mk/Mdl CONTINENTAL IO550
Opr Name: ANDERSON GREG
Hayden, CO
Apt: Yampa Valley HDN
Fatal
0
Ser Inj
Opr dba:
0
Aircraft Fire: NONE
AW Cert: STN
Events
1. Landing-flare/touchdown - Loss of control on ground
Narrative
During a straight in approach to land to runway 28, the pilot flew the airplane with a side slip while maintaining runway centerline. At about ten feet above the
runway a gust of wind blew the airplane right of centerline and the pilot corrected the airplane back to the runway's centerline. Upon touchdown, the pilot
reported that a crosswind blew the airplane's nose to the right, the airplane touched down 10 to 20 degrees right of runway heading, and exited the right side of
the runway, making contact with objects off the runway. Both wings sustained substantial damage. Winds reported on the field about the time of the accident
were 250 degrees at 23 knots with gusts to 29 knots. The pilot reported no mechanical malfunctions or failures with the airplane prior to the accident that would
have resulted in abnormal operation of the airplane.
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04/03/2015 1115 CDT Regis# N8363D
Acft Mk/Mdl ROBINSON HELICOPTER R22 BETA-BETA Acft SN 2745
Opr Name: CODY SEDDEN
Page 101
Fort Davis, TX
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire: NONE
All Rights Reserved
04/05/2015 1424 PDT Regis# N27QV
Acft Mk/Mdl SCHLEICHER ASW 27
Opr Name: SPIELMAN ROBERT
Acft SN 27098
Reno, NV
Apt: N/a
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
1
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: STN
Events
2. Maneuvering - Turbulence encounter
Narrative
On April 5, 2015, about 1424 Pacific daylight time, a Schleicher ASW-27, N27QV, broke up in-flight after entering clouds near Reno, Nevada. The pilot (sole
occupant) sustained serious injuries, and the glider sustained substantial damage throughout. The glider 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 departure phase of the flight, and
no flight plan was filed. The flight originated from the Minden-Tahoe Airport (KMEV) at 0730.
The pilot reported that while maneuvering at 14,000 feet he elected to fly between two large clouds; the clouds filled in quickly and he entered instrument
meteorological conditions. The flight became very turbulent; the pilot felt the glider stall and it started to descend rapidly. The airspeed increased very quickly
and he heard two "pops." At about 9,000 feet the glider exited the clouds and was in a spin. The pilot attempted to recover, but realized the glider's left wing
had separated. He egressed from the glider and parachuted to the roof of a hospital.
The glider's fuselage came to rest on top of a parking garage, the left wing was found in a park, and the right wing has not been located. The glider has been
recovered to a secure location for further examination.
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10/04/2014 1120 EDT Regis# N3619T
Acft Mk/Mdl SCHWEIZER SGS 2 33A
Acft SN 568
Opr Name: SHENANDOAH VALLEY SOARING INC
Waynesboro, VA
Apt: Eagle's Nest W13
Fatal
0
Ser Inj
Opr dba:
0
Aircraft Fire: NONE
AW Cert: STN
Summary
According to the pilot, there were some areas of turbulence during the glider's aero tow to 3,000 feet, but the tow was uneventful. The flight was then smooth
until descent to about 1,200 feet above ground level, when conditions became "bumpy." Upon entering the traffic pattern for runway 24, the pilot increased
normal approach airspeed by 10 knots in anticipation of gusty headwinds on final approach. The approach then proceeded "normally" until short final, when the
glider encountered a "rogue" wind gust that "violently" rolled it about 90 degrees to the right, heading it away from runway centerline. By the time the pilot was
able to level the wings, the glider was too low, necessitating an off-airport landing into small trees that resulted in left wing spar damage. Winds, recorded at a
nearby airport about the time of the accident, were from 260 degrees true at 13, gusting to 19 knots. The pilot did not report any preexisting mechanical
anomalies that would have precluded normal operation.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The glider's inadvertent
encounter with low altitude wind shear.
Events
1. Approach-VFR pattern final - Windshear or thunderstorm
2. Approach-VFR pattern final - Loss of control in flight
3. Approach-VFR pattern final - Course deviation
4. Approach-VFR pattern final - Off-field or emergency landing
5. Approach-VFR pattern final - Collision with terr/obj (non-CFIT)
1. Environmental issues-Conditions/weather/phenomena-Wind-Sudden wind shift-Effect on operation - C
2. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Directional control-Attain/maintain not possible
3. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Descent/approach/glide path-Attain/maintain not possible
Narrative
According to the pilot, there were some areas of turbulence during the glider's aero tow to 3,000 feet, but the tow was uneventful. The flight was then smooth
until descent to about 1,200 feet above ground level, when conditions became "bumpy." Upon entering the traffic pattern for runway 24, the pilot increased
normal approach airspeed by 10 knots in anticipation of gusty headwinds on final approach. The approach then proceeded "normally" until short final, when the
glider encountered a "rogue" wind gust that "violently" rolled it about 90 degrees to the right, heading it away from runway centerline. By the time the pilot was
able to level the wings, the glider was too low, necessitating an off-airport landing into small trees that resulted in left wing spar damage. Winds, recorded at a
nearby airport about the time of the accident, were from 260 degrees true at 13, gusting to 19 knots. The pilot did not report any preexisting mechanical
anomalies that would have precluded normal operation.
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12/07/2014 1443 PST Regis# N27580
Everett, WA
Apt: Snohomish County Paine Field PAE
Acft Mk/Mdl TAYLORCRAFT BL 65
Acft SN 2221
Eng Mk/Mdl CONT MOTOR A-75
Acft TT
Fatal
Opr Name: DYCK DAVID C
Opr dba:
2261
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Summary
The pilot stated that the wheel landing touchdown in the tailwheel equipped airplane was normal. After applying the brakes, the airplane turned 45 degrees to
the left, and departed the runway surface. It crossed the grass infield, went onto a taxiway, and the left wing struck a hangar. The airplane turned right, and the
right wing struck another hangar. Both wings sustained substantial damage. There was no report of a preimpact mechanical malfunction or failure with the
Cause Narrative
directional control during the landing roll resulting in a runway excursion and collision with hangars.
Events
3. Landing-landing roll - Collision during takeoff/land
3. Environmental issues-Physical environment-Object/animal/substance-Airport structure-Not specified
Narrative
The pilot stated that the wheel landing touchdown in the tailwheel equipped airplane was normal. After applying the brakes, the airplane turned 45 degrees to
the left, and departed the runway surface. It crossed the grass infield, went onto a taxiway, and the left wing struck a hangar. The airplane turned right, and the
right wing struck another hangar. Both wings sustained substantial damage. There was no report of a preimpact mechanical malfunction or failure with the
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Accident Rpt# GAA15LA015
03/14/2015 820 MST
Acft Mk/Mdl ULTRAMAGIC SA N210-NO SERIES
Regis# N210UM
Peoria, AZ
Acft SN 210/90
Acft Dmg: MINOR
Fatal
Opr Name: KEVIN WALTER MORGAN
0
Apt: N/a
Ser Inj
Opr dba:
Rpt Status: Prelim
1
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: STB
Events
1. Landing - Hard landing
Narrative
On March 14, 2015 about 0820 Mountain standard time, an Ultramagic SA N210 balloon, N210UM, experienced a hard landing during a visual approach and
landing to an open field in Peoria, Arizona. The pilot and nine out of the ten passengers were not injured. One passenger sustained serious inquires during the
landing sequence. The balloon sustained minor damage to the gondola. The balloon was registered to Float Balloon Tours, L.L.C. of Tempe, Arizona, and
operated by Kevin W. Morgan of Driggs, Idaho, as a day, visual flight rules, passenger flight under 14 Code of Federal Regulations, Part 91. Visual
meteorological conditions prevailed at the time of the accident. The flight originated from private property in Phoenix, Arizona and was conducted in the local
area.
According to the pilot, halfway through the flight, it was determined that winds aloft were faster than anticipated. As the pilot maneuvered the balloon for a
landing in an open field, a hard landing occurred. After landing, it was discovered that one passenger sustained two broken ankles. The gondola sustained
minor damage to the scruff leather coverings.
The pilot reported no mechanical malfunctions or failure with the balloon prior to the flight that would have precluded normal operation of the balloon.
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03/06/2015 1230 PST Regis# N32063
Rio Vista, CA
Apt: Rio Vista O88
Acft Mk/Mdl WACO UPF 7-NO SERIES
Acft SN 5695
Eng Mk/Mdl CONT MOTOR R670-SERIES
Acft TT
Fatal
Opr Name: BAYLEY DONALD T
Opr dba:
1745
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Events
Narrative
The pilot stated that the airplane touched down uneventfully. During the landing roll a gust of wind picked up the right wing, the pilot applied right aileron and
right rudder correction to regain control, but was unable to do so. The pilot lost directional control and advanced the throttle to the full position in an attempt to
execute a go-around, subsequently the left wing came in contact with the ground and ground looped, which resulted in substantial damage to both of the left
wings and left lift struts.
The pilot reported no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Page 106
Air Data Research
All Rights Reserved

National Transportation Safety Board

Transcription

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