General Aviation Reports

Transcription

National Transportation Safety Board - Aircraft Accident/Incident Database
Accident Rpt# CEN14CA460
08/01/2014 1300
Acft Mk/Mdl AVIAT AIRCRAFT INC A 1B-B
Opr Name:
Printed: May 15, 2015
Page 1
Regis# N776BC
Steamboat Sprin, CO
Acft SN 2079
Acft Dmg: SUBSTANTIAL
Rpt Status: Prelim
Fatal
Flt Conducted Under: FAR 091
0
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
Aircraft Fire: NONE
Copyright 1999, 2015, Air Data Research
All Rights Reserved
Accident Rpt# CEN15LA212
04/18/2015 1940 UTC Regis# XXXX
Acft Mk/Mdl BUCKEYE BREEZE-2200
Smithville, TX
Acft Dmg: MINOR
Fatal
Opr Name: HERBERT COWAN
0
Ser Inj
Opr dba:
Rpt Status: Prelim
1
Prob Caus: Pending
Aircraft Fire: NONE
Events
1. Takeoff - Collision during takeoff/land
Narrative
On April 18, 2015 about 1440 central daylight time (cdt), an unregistered Buckeye Breeze 2200 powered parachute, impacted a hangar during takeoff from
Smithville Crawford Municipal Airport (K84R), Smithville, Texas. Visual meteorological conditions prevailed and a flight plan had not been filed. The pilot
received serious injuries. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91.
At 1435, the automated weather observation system at Fayette Regional Air Center Airport (K3T5), located approximately 18 miles southeast of 84R, reported
calm winds.
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09/30/2013 1300 CDT Regis# N8878B
Acft Mk/Mdl CESSNA 172-UNDESIGNAT
Opr Name:
Page 3
Acft SN 36578
Rio Vista, TX
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire:
All Rights Reserved
Accident Rpt# WPR14CA205
05/13/2014 1430
Regis# N5281D
Nampa, ID
Acft Mk/Mdl CESSNA 180A
Acft Dmg:
Eng Mk/Mdl CONT MOTOR O-470 SERIES
Fatal
Opr Name:
0
Apt: Nampa Municipal Airport MAN
Rpt Status: Factual Prob Caus: Pending
Ser Inj
Opr dba:
0
Aircraft Fire:
Summary
The pilot reported that, after an uneventful approach to the runway, he conducted a tail-low, three-point landing in the tailwheel-equipped airplane. About 30 ft
into the landing roll, the airplane suddenly turned sharply right and ground looped. Subsequently, the landing gear collapsed, and the left wing impacted the
ground. Postaccident examination of the tailwheelÿrevealed that, although it wasÿheavily worn, it castered freely. No evidence of a mechanical malfunction or
failure of the tailwheel was found 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
directional control during the landing roll, which resulted in a ground loop.
Events
1. Landing-landing roll - Loss of control on ground
2. Landing-landing roll - Landing gear collapse
3. Landing-landing roll - Ground collision
Findings - Cause/Factor
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
On May 13, 2014, about 1430 mountain daylight time, a Cessna 180A, N5281D, sustained substantial damage to the left wing during a ground loop at the
Nampa Municipal Airport (MAN), Nampa, Idaho. The private pilot and one passenger were not injured. The airplane was owned and operated by the pilot under
the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed, and no flight plan was filed. The flight
originated from MAN at about 1415.
The pilot reported that after an uneventful approach to the runway, he landed the tailwheel equipped airplane in a tail low, three-point landing. About 30 feet into
the landing roll the airplane suddenly turned sharply to the right and ground looped. Subsequently, the landing gear collapsed and the left wing impacted the
ground.
Postaccident examination of the tailwheel by a Federal Aviation Administration inspector revealed the tailwheel was heavily worn; however, it castered freely,
and no anomalies were noted.
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10/24/2014 1715 CDT Regis# N8219M
Acft Mk/Mdl CESSNA 210K-NO SERIES
Opr Name:
Page 5
Acft SN 21059219
Kalamazoo, MI
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire: NONE
All Rights Reserved
06/20/2014 1035 CDT Regis# N455Y
Acft Mk/Mdl GRUMMAN G 164-UNDESIGNAT
Acft SN 101
Anadarko, OK
Acft Dmg:
Fatal
Opr Name:
Page 6
0
Rpt Status: Prelim
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire:
All Rights Reserved
06/16/2014 1315
Regis# N987SL
Acft Mk/Mdl MEYER GEOFFREY A GOAT-NO SERIES Acft SN 1028KCM
Wolcott, CO
Acft Dmg:
Fatal
Opr Name:
Page 7
0
Rpt Status: Prelim
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire:
All Rights Reserved
07/18/2014 2000 CDT Regis# N9034K
Acft Mk/Mdl STINSON 108 1-UNDESIGNAT
Acft SN 108-2034
Bruno, MN
Acft Dmg:
Fatal
Opr Name:
Page 8
0
Rpt Status: Prelim
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire:
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03/14/2014 1030
Acft Mk/Mdl STINSON 108-UNDESIGNAT
Opr Name:
Page 9
Regis# N9538K
Broomfield, CO
Acft SN 108-2538
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire: NONE
All Rights Reserved
Accident Rpt# WPR12LA367
08/25/2012 1152 PDT Regis# N9409E
Pacoima, CA
Apt: Whiteman Airport WHP
Acft Mk/Mdl AERONCA 11AC
Acft SN 11AC-1046
Eng Mk/Mdl CONT MOTOR A&C65 SERIES
Acft TT
Fatal
Opr Name: WASSERMAN ARTHUR
Opr dba:
1998
0
Ser Inj
2
Aircraft Fire: NONE
Summary
Witnesses reported that, while the airplane was on approach for landing, the engine lost power. During the forced landing, the right wing struck a power pole,
and the airplane spun right and subsequently came to rest on top of a cinderblock wall. During on-site wreckage examination, a small amount of fuel was found
in the fuel tanks and on the ground.
Postaccident examination of the engine and airframe revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation.
During postaccident examination of the fuel system, the main fuel tank was found void of fuel. The fuel sump was drained, and the recovered liquid appeared to
be a mixture of aviation fuel and some type of solvent. No other usable amounts of fuel were recovered from the fuel system. It is likely that the combination of
the low fuel level and fuel contamination led to the loss of engine power.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: A total loss of engine power on
approach for landing due to a combination of the low fuel level and fuel contamination.
Events
1. Approach-VFR pattern final - Fuel related
2. Approach-VFR pattern final - Loss of engine power (total)
3. Emergency descent - Collision with terr/obj (non-CFIT)
1. Aircraft-Fluids/misc hardware-Fluids-Fuel-Fluid condition - C
2. Aircraft-Fluids/misc hardware-Fluids-Fuel-Fluid level - C
3. Personnel issues-Task performance-Planning/preparation-Fuel planning-Pilot - F
Narrative
HISTORY OF FLIGHT
On August 25, 2012, at 1152 Pacific daylight time (PDT), an Aeronca 11AC, N9409E, crashed into a parking lot following a loss of engine power near Whiteman
Airport (WHP), Pacoima, California. The owner/pilot was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The
private pilot and the pilot-rated passenger sustained serious injuries; the airplane sustained substantial damage to the right wing and fuselage. The local
personal flight departed WHP about 1130. Visual meteorological conditions prevailed, and no flight plan had been filed.
The airplane pilot had been cleared to land at WHP using runway 12. The airport tower controllers did not receive any distress communication from the airplane
pilot.
The accident site was located in a parking lot, about 1,000 feet northwest of the approach end of runway 12. The parking lot was on the west side of San
Fernando Road in the city of Pacoima.
Witnesses reported seeing the airplane approaching the airport, and noticed that the propeller was not rotating and did not hear any engine noise. The airplane
hit a power pole with the right wing and spun to the right. The airplane came to rest on top of the cinderblock wall between two businesses.
First responders and recovery personnel found limited amounts of fuel on the ground and in the airplane fuel tank.
PERSONNEL INFORMATION
A review of Federal Aviation Administration (FAA) airman records revealed that the 84-year-old pilot held a private pilot certificate with ratings for airplane
single-engine land, and instrument airplane.
A review of the pilot's airman medical records on file at the Airman and Medical Records Center in Oklahoma City, Oklahoma, revealed that the pilot's last
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medical application was dated September 11, 2001. At that time the pilot reported a total time of 4,600 hours; his medical certificate was not valid at the time of
the accident.
On September 31, 2012, the co-owner of the airplane submitted a partially filled out Pilot/Operator Aircraft Accident Report (NTSB Form 6120.1/2). Neither the
pilot nor the pilot-rated passenger provided a statement as to the circumstances leading up to the accident.
AIRCRAFT INFORMATION
The airplane was an Aeronca 11AC, serial number 11AC-1046. A review of the airplane's logbooks indicated that the airplane had a total airframe time of
1,997.8 hours at the last annual inspection dated January 5, 2012. The tachometer read 1,997.8 hours at the last inspection. At the accident scene the
tachometer read 00001.8 hours.
A new tachometer was purchased on June 18, 2012; there was not a corresponding logbook entry indicating the removal and installation of the tachometer.
The logbook entry for the annual inspection noted that the ELT had been inspected.
The engine was a Continental Motors Inc., A-65-A, serial number 1474328. According to the engine logbook, the engine total time since major overhaul, at the
last annual inspection, was 446.0 hours.
No fueling records were located for the accident airplane.
WRECKAGE AND IMPACT INFORMATION
The airplane sustained damage to the right wing and to the engine structure during the impact sequence. The airplane came to rest on top of a cinderblock wall
between two businesses. Both of the pilot yokes were bent toward the left side of the cockpit. The fuselage sustained damage to the left side behind the pilot
door. No damage to the tail section was noted.
TESTS AND RESEARCH
Examination of the recovered airframe and engine was conducted on August 28, 2012, at the facilities of Aircraftsman, Chino, California. No evidence of
pre-impact mechanical malfunction was noted during the examination of the recovered airframe and engine.
The fuel system was inspected and found to contain a minor amount of fuel in the header tank, and the fuel valve was found in the open position. The fuel
selector was found in the OFF position. It was determined that the fire department had selected the fuel selector to the OFF position after the accident.
The sump drain was drained and found to contain a yellowish green fluid that appeared to be a mixture of aviation fuel and some type of solvent possibly
Methyl Ethyl Ketone (MEK).
The ELT was removed from the airplane mounting bracket for examination. The ELT was a Dorne & Margolin Model DM ELT5-2, SN 1808. The ELT was
placarded that it was last inspected on November 12, 1996, and to replace the batteries "NOV 1998" the ELT was opened and contained 6 "D" cell batteries, 3
of which were corroded.
Examination of the engine revealed no catastrophic failures noted to the exterior of the engine. The carburetor assembly was still attached to the engine
assembly by the throttle cable, but had been broken off the intake manifold during the impact sequence.
Examination of the carburetor revealed no abnormalities to the floats or accelerator pump. The filters were all clear. The fuel bowl was void of any fuel and was
otherwise unremarkable.
A Brackett Aero Filter kit was also installed on April 13, 2011, per the engine logbook entry. No record of any 337 forms were filed with the FAA, which is
required.
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The spark plugs were removed and examined. The general conditions of the spark plugs were worn and indicated a rich fuel mixture condition.
A compression check was performed on all 4 cylinders and found to be in the acceptable pressure range. The compression check was conducted with a cold
engine.
ADDITIONAL INFORMATION
The Aeronca AC11, N9409E did not have a transponder installed in the aircraft.Whiteman Airport tower personnel reported that there was no coordination prior
to flight with the pilot of N9409E to conduct flight operations to the airport without a transponder.
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04/11/2015 1034 EDT Regis# N85664
Cambridge, OH
Apt: Cambridge Muni CDI
Acft Mk/Mdl AERONCA 7AC
Acft SN 7AC-4409
Eng Mk/Mdl CONTINENTAL C85-8F
Acft TT
Fatal
Opr Name: DANIEL T. JOHNSTON
Opr dba:
3576
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Summary
The pilot reported that he had landed and was beginning to taxi when a gust of wind lifted the left wing. He added engine power and attempted to correct;
however, he was unable to maintain control. The airplane subsequently departed the runway pavement, encountered a ditch, and overturned. The pilot stated
that there were no failures or malfunctions associated with the airplane before the accident. He reported a 50-degree left crosswind at 10 knots about the time
of the accident.
Cause Narrative
control of the airplane while encountering a wind gust after landing.
Events
2. Landing-landing roll - Runway excursion
3. Landing-landing roll - Nose over/nose down
2. Environmental issues-Conditions/weather/phenomena-Wind-Gusts-Effect on operation
Narrative
The pilot reported that he had landed and was beginning to taxi when a gust of wind lifted the left wing. He added engine power and attempted to correct;
however, he was unable to maintain control. The airplane subsequently departed the runway pavement, encountered a ditch, and overturned. The pilot stated
that there were no failures or malfunctions associated with the airplane before the accident. He reported a 50-degree left crosswind at 10 knots about the time
of the accident.
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05/10/2015 911 CDT
Acft Mk/Mdl AIR TRACTOR INC AT 502B
Opr Name: JORDAN AIR, INC.
Regis# N879JA
Dighton, KS
Acft SN 502B-2879
Rpt Status: Prelim
Fatal
0
Apt: Dighton Airport K65
Ser Inj
Opr dba:
0
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: SPR
Events
1. Initial climb - Loss of engine power (partial)
Narrative
On May 10, 2015, about 0911 central daylight time, an Air Tractor model AT-502B airplane, N879JA, was substantially damaged during a forced landing shortly
after takeoff from Dighton Airport (K65), Dighton, Kansas. The commercial pilot was not injured. The airplane was registered to and operated by Jordan Air Inc.
under the provisions of 14 Code of Federal Regulations Part 91 without a flight plan. Day visual meteorological conditions prevailed for the positioning flight,
which had the intended destination of Dodge City Regional Airport (DDC), Dodge City, Kansas.
According to the pilot, the airplane experienced a partial loss of engine power after he made an initial power reduction during initial climb. The pilot's corrective
actions were not successful in restoring full engine power and a forced landing was made to a nearby muddy field. The right wing, aft fuselage, and tail were
substantially damaged during the forced landing.
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05/05/2015 1241 CDT Regis# N4221G
Acft Mk/Mdl AIR TRACTOR INC AT 502B-B
Acft SN 502B-2668
Basile, LA
Acft Dmg: DESTROYED
Fatal
Opr Name: LEJEUNE AERIAL APPLICATIONS LLC
Apt: N/a
1
Ser Inj
Opr dba:
Rpt Status: Prelim
0
Prob Caus: Pending
Aircraft Fire: GRD
AW Cert: SPR
Events
1. Maneuvering-low-alt flying - Loss of control in flight
Narrative
On May 5, 2015, at 1241 central daylight time, an Air Tractor AT-502B single-engine airplane, N4221G, impacted trees and terrain while maneuvering near
Basile, Louisiana. The commercial pilot, who was the sole occupant, sustained fatal injuries. The airplane was registered to and operated by Lejeune Aerial
Applications, LLC, Basile, Louisiana. Visual meteorological conditions prevailed at the time of the accident and a flight plan was not filed for the 14 Code of
Federal Regulations Part 137 aerial application flight. The local flight departed a private airstrip about 1100.
According to local authorities, the pilot was applying dry granular fertilizer to a rice field. During the last application pass, the airplane contacted trees with the
left wing. The airplane traveled approximately 500 feet and impacted the terrain. A postimpact fire ensued and consumed the airplane.
Examination of the accident site by Federal Aviation Administration inspectors revealed the main wreckage consisted of the fuselage, wings, empennage, and
engine. Flight control continuity was established to all flight control surfaces. Portions of the left wing were located near trees adjacent to the rice field.
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07/29/2014 740 CDT
Acft Mk/Mdl AIR TRACTOR INC AT 502B-B
Opr Name: LARRY GANDY
Page 16
Regis# N502NR
Minden, NE
Acft SN 502B-2817
Rpt Status: Prelim
Acft TT
Fatal
489
0
Apt: N/a
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire: NONE
All Rights Reserved
Accident Rpt# WPR13FA300
06/29/2013 1229 PDT Regis# N684SD
Acft Mk/Mdl ALLSTAR PZL GLIDER SZD-54-2 PERKOZ Acft SN 542.A.10.001
Acft TT
Opr Name: ASSOCIATED GLIDER CLUBS OF
SOUTHERN CALIFORNIA
134
Jacumba, CA
Apt: Jacumba L78
Fatal
2
Ser Inj
Opr dba:
0
Aircraft Fire: NONE
Events
2. Initial climb - Abrupt maneuver
Narrative
HISTORY OF FLIGHT
On June 29, 2013, at 1229 Pacific daylight time, an Allstar PZL Glider, SZD-54-2 Perkoz, N684SD, collided with the ground during the initial climb of a winch
launch at Jacumba Airport, Jacumba, California. The glider was registered to, and operated by, Associated Glider Clubs of Southern California, under the
provisions of 14 Code of Federal Regulations Part 91. The private pilot and airline transport pilot rated passenger sustained fatal injuries; the glider was
substantially damaged. The local flight departed Jacumba, at 1228. Visual meteorological conditions prevailed, and no flight plan had been filed.
The Vice President of the glider club reported that he flew the glider earlier in the day with the same passenger who was on board for the accident. The
passenger had expressed interest in joining the club, and it was an introductory flight. For that flight, they utilized the winch for the launch, and the takeoff and
flight were uneventful, with the glider performing normally.
For the accident flight the pilot (who was the Club President) offered to take the passenger up for a second flight. This was to be the pilot's first flight of the day,
and by now the wind velocity had dropped and minimal lift conditions were present. He indicated that they would therefore perform a flight within the immediate
vicinity of the airport. The passenger sat in the front seat, and the glider was towed back to the launch position at the east end of runway 25, and connected to
the towline.
Witnesses observed the launch sequence, reporting that the ground roll, rotation, and initial climb were uneventful with the glider maintaining a high nose-up
attitude consistent with the first phase of a winch launch. The pilot made an airspeed call of "55" to the winch operator by radio. Immediately after the radio call,
and at an altitude of between 150-300 feet, the towline drogue parachute inflated indicating either a line release at the glider, or a break of the weak-link. The
glider's pitch angle remained the same and the glider then banked to the right, with an accompanying full right rudder deflection. The nose then dropped and the
glider began an erect right spin, colliding with the ground in a nose-down attitude after about 270 degrees of rotation.
Following the accident the towline was examined. It remained continuous to the winch, and the Tost ring, weak-link, and parachute were intact and undamaged.
Pilot
The 54-year-old pilot held a private pilot certificate with ratings for gliders issued in March 2002. No personal flight records were recovered; however, according
to the club vice president, the pilot had undergone a flight review on September 22, 2012. He flew regularly, and was current in the accident glider. He did not
hold an FAA medical certificate, nor was he required to per Federal Aviation Regulations.
Pilot Rated Passenger
The 63-year-old pilot-rated-passenger held an airline transport pilot certificate with ratings for airplane multiengine land, and private privileges for airplane single
engine land. He applied for the airline transport pilot certificate in August 2007, at which time he reported 4,499 total hours of flight experience. He reported prior
military flight experience as an A-6E pilot for the US Navy, and on his most recent application for an FAA medical certificate he reported 1,100 hours of civilian
flight time.
He was issued an FAA first-class medical certificate on January 25, 2013, with the limitation that he wear corrective lenses for near and distant vision.
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GLIDER INFORMATION
SZD-54-2 Perkoz was a two-seat glider with a structure combined of glass and carbon epoxy laminate. The cabin was configured in a tandem arrangement,
with dual flight controls (including tow release).
The glider was manufactured in Poland in 2010, and was imported into the United States where it was registered by the operator under the experimental
classification - exhibition category, in April 2011. According to maintenance logbooks, it had undergone a condition inspection, which was completed on June 7,
2013. At that time, it had accumulated a total flight time of 133.85 hours, over the course of 203 flights.
The glider was approved for winch-launch utilizing the belly hook only, with a recommended winch-launch airspeed of 53 to 59 knots.
METEOROLOGICAL INFORMATION
The closest weather reporting station was located in Campo, California, about 17 miles west of the accident location, and at an elevation of about 2,600 feet. At
1252, the station reported wind from 260 at 10 knots, gusting to 19; temperature of 102 degrees F, dew point 43 degrees F; and an altimeter setting at 29.89
inches of mercury. The resultant density altitude was about 6,000 feet.
The medical examiner investigator who responded to the accident site reported that the temperature was 112 degrees F upon his arrival at 1450.
AIRPORT INFORMATION
Jacumba Airport was comprised of a single gravel runway, 2,508 feet long, by 100 feet wide and oriented on a 07/25 heading. The airport was situated at an
elevation of 2,844 feet mean sea level.
A gravel overrun of about 1,000 feet in length extended beyond the departure end of runway 25, and the terrain within the immediate vicinity of the airport was
composed of flat fields and brush.
The glider came to rest on a westerly heading on the north runway apron about 1,200 feet beyond the initial launch position, and 1,500 feet short of the winch.
Both occupants were situated within the confines of the cabin, which was fragmented through to the wing leading edges. Both wings remained attached to the
fuselage, with the left wing snapped and bending down at the root of the aileron, about 2-feet outboard of the aerodynamic brake. The empennage had
detached from the tailcone, which remained partially attached to the aft cabin bulkhead.
MEDICAL AND PATHOLOGICAL INFORMATION
A postmortem examination was conducted on both occupants by the San Diego County Medical Examiner's Office. The cause of death in both cases was
reported as the effect of multiple blunt force injuries. The FAA Civil Aerospace Medical Institute (CAMI) performed toxicological tests on specimens recovered
by the pathologist.
Pilot
According to the autopsy report, the pilot exhibited mild cardiomegaly (heart weight of 470 grams) with biventricular dilatation. No other natural disease was
identified.
CAMI toxicology results indicated acetaminophen in the urine (120 (ug/ml, ug/g). Acetaminophen is an over-the-counter pain and fever control medication. The
pilot's autopsy vitreous chemistry panel reported:
Glucose 5 mg/dL (Normal < 200)
Chloride 118 mmol/L (Normal 105-135)
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Creatinine 0.6 mg/dL (Normal 0.6-1.3)
Potassium 15.7 mmol/L (Normal < 15)
Sodium 134 mmol/L (Normal 135-150)
VUN (vitreous urea nitrogen) 42 mg/dL (Normal 8-20)
Pilot Rated Passenger
According to the autopsy report, the passenger had coronary artery atherosclerosis with a stent installed at the mid left circumflex coronary artery. The
pathologist did not detect changes in the heart muscle consistent with new or old ischemia (heart attack).
FAA medical records indicated that he had a history of chest pain due to ischemia, which was treated by the stent in 2003. His medications included Ramipril,
a prescription blood pressure control medication, aspirin, and ezetimibe/simvastatin a combination of two prescription cholesterol control medications marketed
as Vytorin. He had passed his most recent follow up nuclear stress test on December 10, 2012.
CAMI toxicology results indicated famotidine in the liver. Famotidine is an over-the-counter acid reducing medication. The pilot's autopsy vitreous chemistry
panel reported:
Glucose 6 mg/dL (Normal < 200)
Chloride 118 mmol/L (Normal 105-135)
Creatinine 0.9 mg/dL (Normal 0.6-1.3)
Potassium 22.7 mmol/L (Normal < 15)
Sodium 128 mmol/L (Normal 135-150)
VUN 32 mg/dL (Normal 8-20)
According to the NTSB Medical Officer, elevated VUN with normal creatinine can occur in the presence of dehydration. Individuals with cardiovascular disease
and dehydration may be prone to decreased cardiac output resulting in dizziness and or degraded cognitive function.
TESTS AND RESEARCH
The glider was recovered from the accident site and examined by the NTSB investigator-in-charge. A complete examination report is contained within the public
docket.
Cabin
The fragmented forward cabin included the remnants of the flight controls, cabin skins, seats, and the canopy. The rudder, elevator, and aileron control
assemblies within the cabin sustained significant crush and fragmentation damage; inspection revealed the damage was consistent with impact forces. Impact
damage prevented an accurate assessment of the trim positions, and no cabin balancing masses were located.
Wings
The right wing outboard leading edge sustained crush damage in an aft direction. The outboard portion of the left wing exhibited similar crush damage, as well
as a tear in the upper skin along the spar. The spar rigging points on both the wings and fuselage were intact. Rotation of the aileron trunnion at both wing roots
resulted in smooth movement of the aileron pushrods at each of the aileron roots. The outboard pushrods were continuous to their associated bellcranks, which
remained attached to the wing spars. Both ailerons remained attached at their hinges. Both aerodynamic brakes were in the partially extended position at the
accident site, but had retracted during the wreckage recovery. Both extended and retracted smoothly when the wing root brake trunnion was rotated. The lack
of damage observed to the brakes was consistent with them being in the retracted position at impact, with impact forces causing them to partially extend.
Empennage
The empennage remained largely intact, with both the elevator and rudder pushrods sustaining bending damage, separating them at the tail break. The rudder
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remained attached to the vertical stabilizer at its hinge points and moved freely. Movement of the rudder resulted in smooth longitudinal movement of its
associated pushrod at the tail break.
The elevator remained attached to the horizontal stabilizer, and sustained minimal damage. Both elevator balance weights had separated from the tips, and
movement of the elevator resulted in smooth uninhibited movement of the elevator control horn/fork. The associated elevator control lifter remained attached to
its bellcrank in the tailcone, with its pushrod intact to through to the tail break.
Tow Hook System
The tow hook release system had separated completely from its respective airframe mounting points, but remained interconnected and functional. The forward
and aft yellow release control handles were continuous to the nose and belly release mechanisms. Both release handles were pulled, and the nose and belly
hooks opened and closed appropriately.
Winch
The glider winch was manufactured by Roman's Design, and was a single-drum type powered by a 325-horsepower diesel engine. The winch line was a 3,800
feet long "synthetic" fiber rope, attached to the glider with a weak link, release parachute, and Tost ring. The glider's maximum winch takeoff speed in the
accident configuration was 59 knots.
The FAA Glider Flying Handbook (FAA-H-8083-13) states the following with regard to normal, into-the-wind ground launch,
"As the launch progresses, the pilot should ease the nose up gradually...while monitoring the airspeed to ensure that it is adequate for launch but does not
exceed the maximum permitted ground launch tow airspeed. When optimum pitch attitude for climb is attained, the glider should be approximately 200 ft AGL.
The pilot must monitor the airspeed during this phase of the climb-out to ensure the airspeed is adequate to provide a safe margin above stall speed but below
the maximum ground launch airspeed. If the towline breaks, or if the launching mechanism loses power at or above this altitude, the pilot has sufficient altitude
to release the towline and lower the nose from the climb attitude to the approach attitude that provides an appropriate airspeed for landing straight ahead."
According to pilots familiar with the Jacumba Airport winch procedures, the towline is generally released by the pilot once the glider has reached an altitude of
between 1,000 and 1,500 feet agl. The club's standard procedure should the line fail below 400 feet, is to land straight ahead.
Weight and Balance
According to the coroner, the passenger located in the front seat weighed 189 pounds, and the pilot in the rear seat weighed 235 pounds. No luggage was on
board, therefore according to the glider's flight manual, with a basic empty weight of 829.37 pounds, it was loaded within 36.33 pounds of its maximum gross
weight of 1,289.7 pounds (when operated in the utility category). In this configuration, the glider was not required to be carrying balancing masses, and none
were installed.
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Accident Rpt# GAA15CA007
03/13/2015 1740
Regis# CFTAD
Afton, WY
Acft Mk/Mdl AVIAT A1 - B-B
Acft SN 2177
Eng Mk/Mdl TEXTRON LYCOMING 0-360-A1P
Acft TT
Fatal
Opr Name: DOUGLASS MILLER TADMAN
Opr dba:
701
0
Apt: Afton Muni AFO
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Summary
The pilot was flying a cross-country flight under visual flight rules in a tailwheel equipped airplane. During the final approach to a full stop landing, the pilot
reported that he flared too high and as a result the airplane bounced and veered to the right. The pilot applied left rudder but was unable to stop the airplane
from departing the runway to the right. During the runway excursion the airplane impacted a snow pile adjacent to the runway and nosed over. The pilot
reported that he typically lands on soft runway surfaces less than 2,000 ft. in length and suspected that his perception during the flare may have been impacted
while landing on this 7,025 ft. runway.
The pilot did not observe any preimpact mechanical malfunctions with the airplane and the winds were reporting calm during the time of the accident.
Examination of the airplane revealed substantial damage to the right wing.
Cause Narrative
directional control during landing.
Events
1. Landing-flare/touchdown - Abnormal runway contact
2. Landing-flare/touchdown - Loss of control on ground
4. Landing-landing roll - Collision with terr/obj (non-CFIT)
2. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Directional control-Not attained/maintained
Narrative
The pilot was flying a cross-country flight under visual flight rules in a tailwheel equipped airplane. During the final approach to a full stop landing, the pilot
reported that he flared too high and as a result the airplane bounced and veered to the right. The pilot applied left rudder but was unable to stop the airplane
from departing the runway to the right. During the runway excursion the airplane impacted a snow pile adjacent to the runway and nosed over. The pilot
reported that he typically lands on soft runway surfaces less than 2,000 ft. in length and suspected that his perception during the flare may have been impacted
while landing on this 7,025 ft. runway.
The pilot did not observe any preimpact mechanical malfunctions with the airplane and the winds were reporting calm during the time of the accident.
Examination of the airplane revealed substantial damage to the right wing.
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08/10/2014 945 CDT
Acft Mk/Mdl BEECH 95 B55 (T42A)-A
Regis# N5812K
Bremond, TX
Acft SN TC-939
Fatal
Eng Mk/Mdl IO470
Opr Name: SHOEMAKER JAMES W
0
Apt: N/a
Ser Inj
Opr dba:
0
Aircraft Fire: NONE
AW Cert: STN
Events
1. Enroute - Fuel starvation
Narrative
The pilot performed a preflight of the airplane, to include fuel selector valves in preparation of an upcoming trip. The purpose of the accident flight was to
reposition to another airport where fuel was available to refuel the airplane. Approximately 30 minutes into the repositioning flight the left engine began to surge
and then quit, followed by the right engine quitting. The pilot was unable to troubleshoot the situation due to his altitude and performed an emergency landing.
The airplane was substantially damaged during the landing. The pilot shutdown the airplane and egressed, positioning the fuel selectors to OFF in the process.
Examination of the airplane revealed fuel present in the main tanks and both axillary tanks were empty. No anomalies were noted with airplane or engines.
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03/11/2015 1243 CDT Regis# N774TA
Osage Beach, MO
Apt: Grand Glaize-osage Beach Arto K15
Acft Mk/Mdl BEECH B19
Acft SN MB825
Eng Mk/Mdl LYCOMING O-320-E3D
Acft TT
Fatal
Opr Name: GDS PROPERTIES
Opr dba:
2451
0
Ser Inj
1
Aircraft Fire: NONE
Events
1. Enroute-climb to cruise - Loss of engine power (total)
Narrative
On March 11, 2015, at 1243 central daylight time, the pilot of a Beech B19, N774TA, ditched in Lake Ozark, Osage Beach, Missouri, after oil pressure was lost
and the engine seized. One passenger was seriously injured, but the pilot and another passenger escaped injury. The airplane was substantially damaged. The
airplane was registered to GDS Properties and operated by the pilot, both of St. Charles, Missouri, under the provisions of 14 Code of Federal Regulations Part
91 as a personal flight. Visual meteorological conditions prevailed at the time of the accident, and no flight plan had been filed. The cross-country flight
originated from Grand Glaize-Osage Beach Airport (K15), Osage Beach, Missouri, about 1225, and was en route to Creve Coeur Airport (1H0), St. Louis,
Missouri.
The pilot told a Federal Aviation Administration (FAA) inspector that everything appeared to be normal when he conducted his preflight inspection, although the
oil did appear darker than usual. There was 6 quarts of oil on the dipstick and the oil had just been changed two days before. During the engine run-up, all
engine instruments were "in the green." Shortly after takeoff, when the airplane had attained an altitude of about 2,800 feet, he noticed the oil pressure was
dropping and he turned back towards K15. Shortly thereafter, the propeller stopped and the engine seized. He ditch in Lake Ozark. The occupants exited the
airplane and climbed out on the wing. The pilot said that as they awaited rescue, he thought he smelled a twinge of burnt oil.
The FAA inspector examined the airplane and verified there was ample fuel on board, and that it was blue in color. He found the throttle linkage connected. The
engine could not be turned by hand. The inspector said he could not find the oil dipstick when the airplane was recovered from the lake. The pilot, however,
was adamant that he had replaced the dipstick after checking the oil.
On April 15 and 16, 2015, the engine was disassembled and examined at Dawson Aircraft in Clinton, Arkansas. The oil dipstick was missing, but more than 4
quarts of oil and only 1 to 2 cups of water were drained from the engine. There were no signs of oil in the engine cowling, and there were no oil streaks
underneath the fuselage.
The no. 2 middle bearing on the crankshaft had seized. The third bearing aft between the two banks of cylinders had rotated, and the bearing for the no. 3
connecting rod had rotated. There was evidence of severe heat distress and mechanical damage to the no. 3 rod bearing. The latter had started squeezing out
the sides of the connecting rod end. The no. 4 piston wrist pin plug was deformed and had damaged the side of the piston. Aluminum pieces and shavings were
noted throughout the engine. The engine parts appeared to have been manufactured by Superior Air Parts, Inc., and not by Textron Lycoming.
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Accident Rpt# CEN15FA214
05/02/2015 0
Acft Mk/Mdl BEECH B35-NO SERIES
Opr Name:
Regis# N5176C
Orange, TX
Acft SN D-2375
Rpt Status: Prelim
Fatal
0
Apt: N/a
Ser Inj
Opr dba:
2
Prob Caus: Pending
Aircraft Fire: NONE
Events
1. Initial climb - Loss of engine power (total)
Narrative
On May 2, 2015, about 1030 central daylight time, a Beech B35, was substantially damaged when it impacted a powerline and then the ground shortly after
takeoff from Orange County Airport (KORG), Orange, Texas. The private pilot and flight instructor were seriously injured. The airplane was registered to Webb
Real Estate Investments Inc. and operated by a private individual under the provisions of 14 Code of Federal Regulations Part 91 as an instructional flight.
Visual meteorological conditions prevailed for the flight, which operated without a flight plan. The local flight was originating at the time of the accident.
Several witnesses observed the airplane wings "rocking" back and forth just prior to the impact with the power lines and terrain. Both wings and the fuselage
were bent and buckled. The engine and empennage separated partially from the airplane. Further examination revealed that the engine had lost power prior to
the impact with the powerlines and was not developing power prior to the accident.
The closest official weather observation station was KORG, located 1/2 nautical mile (nm) south of the accident site. The wind was recorded as 340 degrees at
3 knots. The temperature was 25 degrees C and the dewpoint temperature was 12 degrees C.
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Accident Rpt# ERA13LA370
08/20/2013 1454 EDT Regis# N243RG
Bingham, ME
Apt: Gadabout Gaddis ME08
Acft Mk/Mdl BEECH C23
Acft SN M-2150
Eng Mk/Mdl LYCOMING O-360-A4K
Acft TT
Fatal
Opr Name: AYER RAYMOND L
Opr dba:
3676
0
Ser Inj
0
Aircraft Fire: NONE
Events
5. Initial climb - Aerodynamic stall/spin
Narrative
HISTORY OF FLIGHT
On August 20 2013, about 1454 eastern daylight time, a Beech C23, N243RG, was substantially damaged when it impacted the waters of the Kennebec River
after takeoff from Gadabout Gaddis Airport (ME08), Bingham, Maine. The private pilot and his passenger were not injured. Visual meteorological conditions
prevailed for the personal flight conducted under the provisions of Title 14 Code of Federal Regulations Part 91.
The airplane was owned by the pilot and based at Augusta State Airport AUG), Augusta, Maine. Review of fueling records indicated that the airplane departed
AUG for ME08 with approximately 30 gallons of gasoline in each of the wing tanks. The purpose of the flight was to do an appraisal of a Chevrolet Corvette in
Bingham, Maine for his automobile sales business.
The pilot stated that "it was a non-event going in" to ME08 and that he was familiar with the area having been to a fly-in there.
During his return flight to AUG he departed from runway 31 which was a 2,000 foot long turf runway. During the takeoff, he noticed that the airspeed indicator
appeared to not be working. He then physically "tapped it" with his fingers. He estimated that he was traveling about "60-70" miles per hour. He pulled back on
the control wheel and about 20 feet above ground level the stall warning activated. He then pushed forward on the control wheel to gain airspeed and turned
slightly up river. The right wing then made contact with some trees, and the airplane impacted the waters of the Kennebec River nose first.
According to Federal Aviation Administration (FAA) and pilot records, the pilot who was 59 years old at the time of the accident, held a private pilot certificate
with a rating for airplane single-engine land, Airplane single-engine sea, and instrument airplane. His most recent FAA third-class medical certificate was issued
on January 10, 2011, approximately 2 years and 7 months prior to the accident. He reported that he had accrued 1,141 total hours of flight experience, 950 of
which were in make and model. His most recent flight review was completed on January 25, 2012.
According to FAA and maintenance records the airplane was manufactured in 1979. The airplane's most recent annual inspection was completed on May 22,
2013. At the time of the accident, the airplane had accrued 3675.6 total hours of operation.
No weather broadcast or recording facilities were located at ME08.
The reported weather at the closest weather reporting station located 29 nautical miles northeast of the accident site, at 1456, included: winds calm, 10 miles
visibility, sky clear, temperature 27 degrees C, dew point 15 degrees C, and an altimeter setting of 30.02 inches of mercury.
AIRPORT INFORMATION
Gadabout Gaddis Airport was privately owned. It was uncontrolled and had one runway oriented in a northwest/southeast (31/13) configuration. Runway 31 was
turf, in good condition. The total length was 2,000 feet long and it was 200 feet wide. Obstacles existed in the form of trees which existed on the departure end
of runway 31 where the turf runway ended, and also directly across from the departure end of the runway on an island, which was located 290 feet off the
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departure end of the runway on the opposite side of the Kennebunk River.
Examination of the wreckage by a Federal Aviation Administration (FAA) inspector revealed that the airplane had come to rest upright. The rear fuselage had
separated from the cabin area aft of the baggage door. The flap handle was in the stowed (flaps up) position, and the propeller exhibited S-Bending.
TESTS AND RESEARCH
According to the passenger, on the day of the accident, they tried to land twice and then landed on the third attempt. It was hot, muggy, and very hazy, and that
he could "see the heat." They took off about 1500. The passenger then also advised that the pilot was about halfway down the runway and started tapping a
gauge that told him how fast they were going. He stated that everything happened so quickly, and that when they took off, the airplane stopped climbing, he
heard the pilot say something, and then heard a buzzer at almost the same time. Then they hit a tree with the right wing and crashed.
According to a witness, she was trying to take a photograph of the airplane as it took off when the crash occurred. During the takeoff, the airplane was about
halfway down the runway and it started to make her nervous. It then "took off" but it looked like the airplane was not "getting enough air." She then saw the
airplane's right wing clip the trees at the end of the runway. The airplane then "spun" around and landed on the airplane's nose and then the tail.
According to the airport manager, it was hot and muggy and the pilot had made multiple attempts to land prior to touching down at the airport. During the takeoff
attempt by the pilot there was a crosswind, the airplane "kinda" went up, stalled, and then the nose dropped and it clipped a tree.
Density Altitude
By utilizing the National Oceanic and Atmospheric Administration's density altitude calculator, investigators determined that density altitude at the time of the
accident was approximately 3, 218 feet
According to FAA's Density Altitude Pamphlet (FAA-P-8740-2), density altitude has particular implications for takeoff/climb performance and landing distance,
pilots must be sure to determine the reported density altitude and check the appropriate aircraft performance charts carefully during preflight preparation.
A pilot's first reference for aircraft performance information should be the operational data section of the aircraft owner's manual or the Pilot's Operating
Handbook developed by the aircraft manufacturer.
A pilot who is complacent or careless in using the charts may find that density altitude effects create an unexpected-and unwelcome-element of suspense
during takeoff and climb or during landing.
If the airplane flight manual (AFM) is not available, Pilots should use the Koch Chart to calculate the approximate temperature and altitude adjustments for
aircraft takeoff distance and rate of climb.
Review of AFM and Koch Chart
Review of the Beechcraft C23 FAA Approved AFM revealed that it contained performance information for takeoff distance on grass surfaces. The published
information indicated that at gross weight at 27 degrees Celsius, with no wind, and full throttle, mixture leaned to maximum rpm then enrichened slightly, that
takeoff ground roll would be approximately 1,374 feet, and that total distance to clear a 50 foot obstacle would have been approximately 2,300 feet.
Review of a Koch Chart also indicated that due to the higher than standard temperature of 27 degrees Celsius, that an approximate 40 percent increase in the
airplane's normal takeoff distance would have occurred during takeoff, along with a 30 percent decrease in rate of climb.
Airspeed Indicator
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Despite the pilot's and passenger's statements about the airspeed indicator to the NTSB, during an interview with a newspaper reporter the pilot stated that "I
can't get my head around it. There was nothing weird." The passenger also stated to the reporter that he did not know anything was wrong until the airplane hit
the trees at the end of the runway and he felt the tail break off. There was a loud bang, and they landed in the river.
After the accident, the airport manager looked at the pitot tube which captures ram air for use by the airspeed indicator but did not see any blockages.
Further examination of the airplane by the FAA also did not reveal any evidence of any preimpact failures or malfunctions of the airplane or engine, which
would have precluded normal operation of the airplane.
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03/20/2014 2045
Regis# N28119
Salt Lake City, UT
Acft Mk/Mdl BELLANCA 17 31-ATC
Acft SN 78-31146
Eng Mk/Mdl LYCOMING IO-540 SER
Acft TT
Fatal
Opr Name: GREGORY G PAGE DDS PC
Opr dba:
2342
0
Ser Inj
Apt: Salt Lake City Intl Airport SLC
0
Aircraft Fire: NONE
Summary
The pilot reported that, during the approach, he conducted his usual prelanding checklist, which included verifying the landing gear position and indicator lights
four separate times. He conducted an uneventful touchdown; however, during the landing roll, the right main landing gear collapsed. Postaccident examination
of the landing gear revealed that the right main landing gear extension spring appeared to be compressed, and, when tested, it only produced 19 to 20 pounds
of pressure. It is likely that this reduced pressure was notÿsufficient to maintain the extension of the right main landing gear. The nose and left main landing
gear extension springs were also tested, and they produced about 40 pounds of pressure. The pilot reported thatÿthree new springs, all of which produced 44
pounds of pressure, were subsequently installed on the airplane, andÿno further landing gear system anomalies were reported afterÿflight testing.ÿ
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The failure of the right main
landing gear extension spring to maintain adequate pressure, which allowed the landing gear to collapse during the landing roll.ÿ
Events
1. Aircraft-Aircraft systems-Landing gear system-Main landing gear-Failure - C
2. Aircraft-Aircraft systems-Landing gear system-Gear extension and retract sys-Malfunction - C
Narrative
On March 20, 2014 about 2045 mountain daylight time, a Bellanca 17-31ATC, N28119, sustained substantial damage after the landing gear collapsed at the
Salt Lake City International Airport (SLC), Salt Lake City, Utah. The pilot, the sole occupant, was not injured; the airplane sustained substantial damage to the
right wing aileron. The airplane was registered to, and operated by, the pilot under the provision of 14 Code of Federal Regulations Part 91 as a personal flight.
Visual meteorological conditions prevailed for the flight, and no flight plan was filed. The flight originated from the Roosevelt Municipal Airport (74V), Roosevelt,
Utah at about 1950.
The pilot reported that during the approach he conducted his usual pre-landing checklist, which included verifying the landing gear position and indicator lights
four separate times. He conducted a normal, uneventful landing. During the landing roll the landing gear warning indication light activated and the right main
landing gear green indicator light extinguished. The right wing dropped to the runway and the airplane slid before coming to a rest just off of the runway surface.
Postaccident examination of the landing gear by a mechanic and the pilot revealed that the right main landing gear extension spring appeared to be
compressed; when tested, it produced 19-20 pounds of pressure. The extension springs from the nose and left landing gear assemblies were also removed and
tested; they both produced about 40 pounds of pressure.
The pilot reported that he subsequently purchased and tested three new springs, all of which produced about 44 pounds of pressure. The new springs were
installed on the airplane and no further landing gear anomalies were noted.
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04/30/2015 1947 PDT Regis# N2514N
Acft Mk/Mdl CESSNA 140-G
Opr Name: KEVIN LEAVITT
Acft SN 12771
Crescent Lake, OR
Apt: N/a
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
0
Prob Caus: Pending
Aircraft Fire: NONE
Events
1. Enroute-cruise - Fuel starvation
Narrative
On April 30, 2015, about 1947 Pacific daylight time, a Cessna 140, N2514N, sustained substantial damage during a forced landing following a reported loss of
engine power, near the Crescent Lake State Airport (5S2) Crescent Lake, Oregon. The airplane was registered to and operated by the pilot under the provisions
of Title 14 Code of Federal Regulations Part 91. The airline transport pilot was not injured and the passenger sustained minor injuries. Visual meteorological
conditions prevailed and no flight plan was filed for the personal flight. The flight originated from Rogue Valley International - Medford Airport (MFR), Medford,
Oregon at an undetermined time, with a destination of Sisters Eagle Air Airport (6K5), Sisters, Oregon.
The pilot reported that during cruise flight, about 2,500 feet mean sea level (msl), the engine lost power when the selected fuel tank was run empty. He
switched fuel tanks but was unable to restart the engine. The pilot stated that when he realized that he would not be able to make the airport, he initiated a
forced landing in a nearby road. During the landing, the airplane struck trees but remained upright, on a road about 2 miles South from 5S2.
A postaccident examination of the airplane by a Federal Aviation Administration inspector revealed that the right wing sustained substantial damage. The
airplane was recovered to a secure storage facility for further examination.
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Accident Rpt# WPR15LA154B 04/24/2015 1200 PDT Regis# N6211K
Van Nuys, CA
Acft Mk/Mdl CESSNA 150M-M
Rpt Status: Prelim
Fatal
Acft SN 15077588
Eng Mk/Mdl CONT MOTOR 0-200 SERIES
Opr Name: CONTINENTAL AVIATION INC
0
Ser Inj
Opr dba:
0
Prob Caus: Pending
Aircraft Fire: NONE
Events
1. Taxi - Ground collision
Narrative
On April 24, 2015, about 1200 Pacific daylight time, a Cessna 150M, N6211K, and a Diamond DA20, N309EF, sustained damage during a ground collision at
Van Nuys Airport (VNY), Van Nuys, California. The Cessna sustained substantial damage and the Diamond sustained minor damage. The private pilot and pilot
rated passenger of the Cessna, and the student pilot and certified flight instructor aboard the Diamond were not injured. Visual meteorological conditions
prevailed, and no flight plan was filed for either of the local flights, which were both conducted under the provisions of Title 14 Code of Federal Regulations Part
91.
According to the pilot of the Cessna, he was taxiing to the airport's run-up area via taxiway Alpha when he noted another aircraft at his 10 o'clock position
entering his pathway. He reported that he applied brakes; however, the two airplanes collided on the taxiway.
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07/05/2014 1700 CDT Regis# N49785
Acft Mk/Mdl CESSNA 152-NO SERIES
Acft SN 15283514
Eng Mk/Mdl LYCOMING 0-235 SERIES
Opr Name: US AVIATION GROUP LLC
Denton, TX
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
0
Prob Caus: Pending
Aircraft Fire: NONE
Events
1. Enroute-cruise - Aircraft structural failure
Narrative
On July 5, 2014, about 1730 central daylight time, a Cessna C-152, N49785, received substantial damage when a wing spar broke in flight. The commercial
pilot and private pilot onboard were not injured. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations
Part 91 as a personal flight. Visual meteorological conditions prevailed at the time of the accident, and a VFR flight plan had been filed. The flight originated
from Graham Municipal Airport (RPH), Graham, Texas, and terminated at Denton Municipal Airport (DTO), Denton, Texas.
The pilots stated they had flown three hours and conducted a series of practice approaches. They were in cruise flight returning to DTO at 3,500 feet MSL after
completing the approaches when they heard a "loud bang." They could not determine the source of the noise before landing. During post flight inspection of the
airplane they discovered a hole in the top of the right wing near the fuel cap. Further inspection revealed the rear wing spar had broken near that point.
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10/04/2014 1830 CDT Regis# N124RP
Acft Mk/Mdl CESSNA 152-NO SERIES
Opr Name:
Page 32
Acft SN 15282139
Arlington, TX
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire: NONE
All Rights Reserved
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
Summary
The flight instructor and the student pilot, accompanied by a passenger-observer, were conducting the instructional flight in one of their flight school's airplanes.
The student pilot, who had a total flight time of 4 hours and for whom this was his fourth flight, was handling the controls. During the takeoff roll, his
overcorrections caused the airplane to veer right and then left. After crossing the centerline from right to left and when the airplane was heading toward the left
edge of the 100-ft-wide runway, the flight instructor took the controls but was unable to maintain airplane control. He attempted to lift off, and the airplane
became airborne momentarily, but the nose dropped, the airplane banked right, and it then struck the runway. The airplane nosed over inverted and came to a
stop. The pilots 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 student pilot's excessive
directional control inputs during the takeoff roll and the flight instructor's delayed and ineffective corrective actions, which resulted in the loss of airplane control.
Events
1. Takeoff - Loss of control on ground
1. Personnel issues-Action/decision-Info processing/decision-Decision making/judgment-Instructor/check pilot - C
2. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-(general)-Not attained/maintained - C
3. Personnel issues-Task performance-Use of equip/info-Use of equip/system-Student/instructed pilot - C
4. Personnel issues-Psychological-Attention/monitoring-Monitoring other person-Instructor/check pilot - C
5. Personnel issues-Action/decision-Action-Delayed action-Instructor/check pilot - C
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.
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
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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.
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.
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.
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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Accident Rpt# ERA15FA203
05/03/2015 1134 EDT Regis# N3969L
Penn Yan, NY
Apt: Penn Yan PEO
Acft Mk/Mdl CESSNA 172G
Acft SN 17254138
Rpt Status: Prelim
Eng Mk/Mdl CONT MOTOR O-300
Acft TT
Fatal
Opr Name: SEELY STEVEN P
Opr dba:
4625
1
Ser Inj
0
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: STN
Events
1. Initial climb - Aerodynamic stall/spin
Narrative
On May 3, 2015, at 1134 eastern daylight time, a Cessna 172G, N3969L, impacted terrain and a perimeter fence during climb after a touch and go landing at
the Penn Yan Airport (PEO), Penn Yan, New York. The student pilot was fatally injured. Visual meteorological conditions prevailed and no flight plan was filed
for the flight which departed from Finger Lakes Regional Airport (0G7), Seneca Falls, New York at about 1115. The flight was conducted under the provisions of
Title 14 Code of Federal Regulations Part 91.
A pilot-rated witness observed the airplane in the traffic pattern for runway 19 (5499' x 100') prior to the accident. He stated that as the airplane turned left from
onto the base leg of the traffic pattern, it was in a "very aggressive slip". About the same time, he observed the windsock and estimated the winds to be from
about 320 degrees, and "greater than 10 knots." He stated that while on final approach, the airplane appeared to be "high and fast." He estimated its height to
be about 100 to 150 feet above the ground as it crossed over the runway threshold, and it then appeared to "float" down the runway. He then lost sight of the
airplane behind terrain and obstructions, and realized that the airplane had crashed when he several minutes later saw first responders arriving at the airport.
He noted that during the landing approach, the flaps appeared to be fully extended, the propeller was rotating, and the engine sounded as if it were at idle
speed.
Another witness was located on a golf course adjacent to the airport, at near the mid-point of runway 19. When he first saw the airplane, it was almost abeam
his position adjacent to the runway, and it looked like it was taking off. He elaborated that the engine sounded "normal," and the climb appeared normal from
the time the wheels left the ground, until a height of about 50 feet. At that point the airplane began climbing at a faster rate than it had been previously, and
banked to the left. The airplane also appeared to be higher and climbing faster than other airplanes he had previously observed at about the same location. The
airplane then descended, while continuing the left banking arc as if the left wing was "tied to the ground with a string".
The pilot held a student pilot certificate and Federal Aviation Administration (FAA) third-class medical certificate, which was issued on January 20, 2014. To
date, his pilot logs had not been recovered. According to the pilot's flight instructor, the pilot had been endorsed for solo flight around October 2014, and had
accumulated an estimated 40 total hours of flight experience.
The 1135 weather observation at PEO included wind from 310 at 8 knots, 10 miles visibility, clear skies, temperature 73 F, dewpoint 37 F, altimeter setting
30.08 inches of mercury.
The airplane came to rest upright with the right wing resting on the airport perimeter fence, about 300 feet to the left of the runway centerline, about 2,800 feet
from the runway 19 approach threshold. All of the major components of the airplane were accounted for at the accident site. Areas of disturbed soil and
intermittent ground scars extended from the initial impact point oriented on a heading of 145 degrees magnetic. A piece of left wing navigation light was located
in the wreckage path about 20 feet from the initial impact point. About 15 feet further down the path, a ground scar was found oriented 90 degrees to the path,
about the length of the propeller diameter and the width of a propeller blade. About 2 feet further was an impact crater 3 feet wide and 8 feet in length containing
paint chips and fragments of wind screen, followed by the main wreckage, which had come to rest oriented on a heading of about 340 magnetic.
The propeller remained attached to the crankshaft flange, and both blades displayed s-bending, chordwise scratching, and leading edge gouging. The engine
remained partially attached to the firewall by its mounts. The nose landing gear was fractured and separated from the airplane at the firewall attachment point,
consistent with impact. The nose section from the firewall forward had separated from the fuselage on both sides, and the windscreen was fractured and
separated from the fuselage. The outboard portion left wing was deformed upward, and displayed aft crush damage consistent with ground contact. The right
wing displayed a concave depression and was deformed aft beginning outboard of the wing strut.
First responders reported that upon their arrival they observed fuel leaking from the left wing in the area of the vent tube, and subsequently drained about 7
gallons from the left wing, and about 10 gallons from the right wing. Fuel samples from both tanks displayed a color and odor consistent with automotive
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gasoline, and a trace amount of water was detected in the sample from the left wing and in fuel recovered from the carburetor float bowl.
Flight control continuity was established from each control surface to the cockpit area. The elevator trim tab actuator position was consistent with 5-10 degrees
of tab deflection in the nose up direction. The flap actuator extension was measured, and found in a position consistent with a 40-degree flap extension. The
front seat tracks and seat roller brackets for both seats were checked for wear, and found to be within prescribed limits. The left seat positioning rod was found
bent forward about 1-inch from the engagement end.
The engine crankshaft was rotated by hand at the propeller flange and continuity of the valve and powertrains was confirmed to the rear accessory gears. The
oil screen and paper oil filter element were unobstructed and absent of metallic contamination. The spark plugs were removed and the #6 cylinder plugs
displayed black-colored carbon-type fouling. Thumb compression was confirmed on all cylinders. The fuel strainer screen and carburetor inlet screen were
absent of debris. The carburetor floats were intact, and both displayed concave inward uniform deformation. The magnetos and were removed and actuated by
hand, and spark was observed at each of their respective terminal leads.
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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
Summary
After an uneventful instructional flight, the student pilot entered the left downwind leg of the traffic pattern while the airplane was at 1,200 ft mean sea level. The
flight instructor then asked the student to turn onto the base leg of the traffic pattern, but "he was slow to respond," and the airplane was too fast, which
extended the downwind leg farther out than normal. The flight instructor then noticed that the student had not extended the wing flaps to the 10-degree position.
The student pilot then extended the wing flaps to 10 degrees and started to slow the airplane. The flight instructor then asked the student to turn onto final, and,
because of the extended downwind leg, to stop descending and add power. The student then arrested the descent, but he failed to add power as instructed.
The flight instructor again asked the student to add power; however, the student did not respond by either adding power or by asking the flight instructor for
clarification. The flight instructor stated that he was distracted by the airplane's airspeed and altitude and the student's lack of response and that he did not see
the power lines during the final approach even though he had flown over them many times. When he finally did see the power lines, he took control of the
airplane and then added full power and maximum up elevator. However, the airplane struck a static wire that ran along the top of the power poles, nosed over,
and impacted terrain. Review of Federal Aviation Administration records revealed that the student pilot held a third-class medical certificate with the limitation
that he "must use hearing amplification." However, the student pilot was not wearing a hearing aid during the accident flight; therefore, he might not have heard
the flight instructor's command to increase engine power, which would explain his failure to do so as instructed. Further, neither the student pilot nor the flight
instructor were wearing headsets in the loud cockpit of the single-engine airplane, which also could have made it difficult for the student pilot to hear the flight
instructor's command.Although the power lines were not included in the airport information in the Airport/Facility Directory, they were depicted in the sectional
aeronautical chart for the area. Examination of the power lines revealed that not only were they below the runway's 7.00-degree glidepath that was provided by
a pulsating visual approach slope indicator to ensure obstacle clearance but that they were also below the obstruction identification surfaces listed in federal
regulations, and, in many areas, they were at or below the trees located on the approach end of the runway. Given this information and the fact that the flight
instructor had flown over them many times, the power lines should not have been a hazard. The flight instructor's slow response to the student pilot's failure to
increase power during the descent led to the airplane's collision with the wire.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The student pilot's failure to
increase engine power during the descent for landing when instructed to do so by the flight instructor and the flight instructor's delayed remedial action, which
resulted in collision with a static wire. Contributing to the accident was the student pilot's failure to use hearing amplification as required by his Federal Aviation
Administration medical certificate.
Events
1. Approach-VFR pattern final - Controlled flight into terr/obj (CFIT)
2. Uncontrolled descent - Collision with terr/obj (non-CFIT)
1. Personnel issues-Physical-Health/Fitness-Predisposing condition-Student/instructed pilot - F
2. Personnel issues-Action/decision-Action-Lack of action-Student/instructed pilot - C
3. Personnel issues-Psychological-Attention/monitoring-Monitoring other person-Instructor/check pilot - C
4. Personnel issues-Action/decision-Action-Delayed action-Instructor/check pilot - C
5. Environmental issues-Physical environment-Object/animal/substance-Wire-Awareness of condition - C
6. Environmental issues-Physical environment-Object/animal/substance-Wire-Response/compensation - C
7. Environmental issues-Physical environment-Object/animal/substance-Wire-Effect on equipment - C
8. Personnel issues-Psychological-Attention/monitoring-Monitoring environment-Instructor/check pilot - C
9. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Altitude-Not attained/maintained - C
10. Personnel issues-Action/decision-Info processing/decision-Identification/recognition-Instructor/check pilot - C
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
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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.
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.
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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.
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
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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.
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
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.
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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Accident Rpt# WPR13FA211B 04/29/2013 1401 PDT Regis# N64030
Calabasas, CA
Apt: N/a
Acft Mk/Mdl CESSNA 172M
Acft SN 17264976
Acft Dmg: DESTROYED
Eng Mk/Mdl LYCOMING O-320 SERIES
Acft TT
Fatal
Opr Name: STRAWN CHERYL
Opr dba:
5862
2
Ser Inj
1
Aircraft Fire: GRD
AW Cert: STN
Events
1. Enroute-cruise - Midair collision
Narrative
HISTORY OF FLIGHT
On April 29, 2013 about 1401 Pacific daylight time, two airplanes, a Cessna 172RG, N4677V (172RG), and a Cessna 172M, N64030 (172M), collided in midair
approximately 3 miles southwest of Calabasas, California. The 172RG certified flight instructor and the commercial pilot sustained minor injuries, and the pilot
rated passenger sustained serious injuries; the airplane sustained substantial damage to the left wing. The 172RG was registered to AmeriFlyers of Florida,
LLC, and operated by American Flyers as a 14 Code of Federal Regulations (CFR) Part 91 instructional flight. The 172M commercial pilot and private pilot were
fatally injured, and the airplane was destroyed. The 172M was registered to a private party, and operated by the commercial pilot under the provisions of 14
CFR Part 91 as a personal flight. Visual meteorological conditions prevailed, and no flight plan was filed for either flight. The 172M departed from the Santa
Monica Municipal Airport (SMO), Santa Monica, California about 1313, and the 172RG departed from SMO about 1353.
The certified flight instructor (CFI) from the 172RG reported that the purpose of the flight was to familiarize two pilot rated students (one of which was seated in
the back seat) with the local airspace and normal practice areas. After departing SMO they flew north along the Santa Monica shoreline before proceeding to
the Malibu State Park and the Simi Valley practice area. As they crossed over Topanga Canyon, they switched from the SMO tower frequency to the local
practice area frequency and made the first position report transmitting "Malibu and Simi Valley practice area, white Cessna, over Topanga Canyon, northbound
at 2,800 climbing 3,500". They leveled off at 3,500 feet and the CFI asked the pilot in the right seat to perform the cruise checklist. The CFI made a second
radio call transmitting, "Malibu and Simi Valley practice area, white Cessna, over Calabasas, south of the 101, east of Malibu Canyon Road heading west
towards Westlake 3,500." No airplanes acknowledged their position reports nor did any other airplanes transmit a nearby position.
The pilot under instruction then conducted a right clearing turn from a westerly heading to a northerly heading and then brought the airplane back to the left and
leveled off on the original westerly heading. The CFI reported that he was looking to the front and the left in his normal traffic scan practice. When the airplane
had leveled off, he heard a loud bang and felt something hit the airplane on the left side. He looked outside at the left wing and noticed that the inboard leading
edge was damaged from the wing root outboard, the pitot tube was missing and the left wing strut was bent. The pilot's side window was also broken and metal
was protruding into the airplane. The CFI took control of the airplane and, unable to maintain altitude, executed a forced gear up landing onto a golf course. The
airplane slid about 430 feet when the left wing impacted a tree that spun the airplane about 180 degrees before it came to a rest.
A witness reported that he and his wife were walking in the area when they heard an extremely loud strike. He looked up and saw an airplane descending
almost vertically to the ground before it went out of his view; he did not note hearing an engine noise. Shortly after, he saw a plume of dark smoke rise from
where the airplane had disappeared. The witness further reported that his wife observed a second airplane depart the area to the west.
Review of the radar data revealed that the Cessna 172RG was observed on radar immediately after departure from SMO at 13:51:32 until shortly after the
collision occurred. At 14:01:04, the airplane's transponder return showed 3,500 feet mean sea level (msl) with a westerly track and a ground speed of 104
knots. At about 14:01:14 the track indicated the start of a gradual right 6 degree turn towards the northwest at a ground speed of 103 knots. At about 14:01:46
the airplane maintained a heading of 266 degrees until the collision occurred at 14:01:55 at 3,400 feet msl (about 2,540 feet above the ground). After the
collision, the airplane's track continued to the north followed by a left turn towards the west and a right turn to the northwest. The last radar return was at
14:02:32 at an altitude of 2,800 feet msl.
At 13:58:23 the Cessna 172M is identified on radar cruising in an easterly direction at 3,200 feet msl at 110 knots. At 13:59:00 the transponder return indicated
the airplane was at 3,200 feet msl and the track showed the start of a gradual left turn at 111 knots. At 14:01:09 the airplane was at 3300 feet msl, and at
14:01:28 the airplane was at 3400 feet msl flying at 100 knots. The collision occurred at 14:01:55. The airplane track made a sharp left turn and descended
rapidly into terrain.
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Cessna 172RG Flight Crew
The CFI, age 37, held an airline transport pilot certificate for airplane single- and multi- engine land issued December 22, 2012. The CFI also held a flight
instructor certificate for airplane single- and multi-engine land, which was issued February 19, 2012. His second-class airman medical certificate was issued on
May 11, 2012 with no limitations. The CFI had a total of 2,200 total flight hours, 600 of which were in the accident airplane make and model.
The pilot under instruction, age 34, held a commercial pilot certificate for airplane single- and multi- engine land issued on January 20, 2013. The second pilot's
first-class airman medical certificate was issued on November 20, 2012 with the limitation that he must wear corrective lenses. The second pilot reported 485
total flight hours; the accident flight was his first flight in the accident airplane make and model.
Cessna 172M Flight Crew
The first pilot, age 69, held a commercial pilot certificate for airplane single-engine land issued on October 29, 2003. The pilot also held a flight instructor
certificate for airplane single-engine land which was issued on July 25, 2011. The pilot's third-class airman medical certificate was issued on March 5, 2012,
with the limitation that she must wear corrective lenses. The pilot's logbook was not located. On the pilot's application for her most recent medical examination
she reported 1,750 total flight hours, 50 of which occurred within the six months preceding the examination.
The second pilot, age 63, held a private pilot certificate for airplane single-engine land issued May 10, 2010, and a certified airframe and powerplant mechanic
certificate issued on February 18, 2010. The pilot's third-class airman medical certificate was issued on December 6, 2011 with no limitations. On the pilot's
application for his most recent medical examination he reported 1,350 total flight hours, 25 of which occurred within the six months preceding the examination.
Cessna 172RG
The Cessna 172RG, serial number 172RG0224, was manufactured in 1980, and was a four seat, high wing airplane that was predominately white in color with
blue striping. The airplane was powered by a Lycoming O-360 series, 180 horsepower engine, and was equipped with a 2 blade McCauley propeller. The
airplane was registered to Ameriflyers of Florida LLC, and operated by American Flyers. The airplane's most recent maintenance was a 100 hour inspection
that occurred on April 5, 2013 at an airframe total time of 10,383.
Recovery personnel reported that during the recovery, about 43 gallons of fuel was removed from the fuel tanks.
Cessna 172M
The Cessna 172M, serial number 17264976, was manufactured in 1975, and was a four seat, high wing airplane that was predominately white in color with red
and blue striping. The airplane was powered by a Lycoming O-320 series, 180 horsepower engine, and was equipped with a 2 blade McCauley propeller. The
airplane was registered to a private individual and operated by the commercial pilot. Review of the maintenance records indicated that on April 16, 2013, at an
airframe total time of 58,623, the airplane's engine and propeller were reinstalled onto the airplane from a previous incident involving a propeller strike. The
airplane's most recent annual inspection also occurred that day.
The nearest weather reporting station was located about 9 nautical miles northeast of the accident site at the Van Nuys Airport (VNY), Van Nuys, California. At
1351, VNY reported clear skies, wind 140 degrees at 6 knots, visibility 10 statute miles, temperature 17 degrees C, dewpoint 11 degrees C, and an altimeter
setting 29.82 inches of mercury.
COMMUNICATIONS
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The Federal Aviation Administration (FAA) reported that at 1313, the 172M pilot contacted Santa Monica air traffic control tower and requested to stay in the
pattern following maintenance. At 1340, the pilot requested a departure to the west. The controller approved the request, and terminated services.
At 1353, the 172RG pilot requested clearance to depart SMO to the west to follow the shoreline northbound. The request was approved and shortly thereafter
services were terminated.
There was no evidence of the two airplanes communicating with each other.
Cessna 172RG
The airplane landed onto the golf course hard and dug into the fairway grass. The grass and concrete showed sliding marks for about 430 feet along a bearing
of about 73 degrees magnetic, followed by a tree, and then the main wreckage. The main wreckage was orientated from tail to nose on a bearing of 253
degrees magnetic.
The airplane's left wing leading edge sustained two large indentations. One indentation was located at the wing root and was approximately three feet long.
Within the damaged wing root were distinct white and red diagonal paint transfer marks that were at about a 50 degree angle when compared to the nearest
longitudinal rivet line. The outboard dent was located about 2.5 feet from the wing tip and was about three feet long. Within the dent were brownish red scrape
marks as well as tree residue imbedded in the dent. The left strut sustained a dent approximately 2 feet from the bottom of the left wing. One of the propeller
blades had a one inch gouge along the leading edge about 6 inches from the propeller tip. The left side door posts were bent aft, and the upper portion of the
back center window post was bent to the right. The empennage remained intact and mostly undamaged.
About four pieces of right horizontal stabilizer and elevator with red and blue striping were found on the ground resting near the left horizontal stabilizer of the
172RG. Scratch marks were noted along the upper outboard portion of the largest horizontal stabilizer piece. These scratch marks were measured to be at
about a 50 degree angle when compared to the nearest longitudinal rivet line.
Cessna 172M
The wreckage of the 172M was located at an elevation of 1,170 feet on a mountain side about 5 miles southeast of Westlake Village, California.
The airplane impacted the ground in a nose low attitude and a postimpact fire ensued; the wreckage was heavily burned and no paint transfers or obvious
scratches from the collision were noted. The engine was separated from its engine mounts and the propeller was separated from the engine. The airframe
sustained forward accordion crushing throughout. The flap actuator was located and the flaps were in the up position. The flight control cables were traced
throughout the airframe and control continuity was established from the cabin controls to their respective flight control surfaces. The right horizontal stabilizer
and the elevator were separated from the forward horizontal stabilizer spar about 6 inches from the spar root. A small portion, which was believed to be the
inboard portion of the right horizontal stabilizer, was found within the wreckage. The remaining components of the right horizontal stabilizer and elevator were
not present on scene, however, they were found on scene with the 172RG.
Postaccident examination of the engine from the 172M revealed heavy thermal discoloration throughout. The cylinder rocker covers were removed; the valves
were intact and sustained thermal discoloration. The right magneto was separated from the engine, and the left magneto remained attached. The ignition leads
were consumed by fire. The spark plugs were removed and exhibited wear consistent with "Worn Out - Normal" when compared to the Champion AV-27
check-a-plug chart. When viewed from the spark plug holes, the interior surfaces of the cylinders and piston heads revealed no signs of internal catastrophic
damage.
The autopsies of the pilots from the Cessna 172M were performed by the Los Angeles County Department of Coroner, Los Angeles, California.
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The first pilot's autopsy was conducted on May 1, 2013, and concluded that the cause of death was multiple traumatic injuries. Specimens from the autopsy
were sent to the FAA's Civil Aerospace Medical Institute (CAMI) in Oklahoma City, Oklahoma, and toxicological tests were performed. The results were
negative for ethanol and drugs in the pilot's liver or muscle; tests for carbon monoxide and cyanide were not performed.
The second pilot's autopsy was conducted on May 2, 2013, and concluded that the cause of death was multiple traumatic injuries. Specimens from the autopsy
were sent to the FAA's CAMI and toxicological tests were performed. The results were negative for ethanol and drugs in the pilot's liver or muscle; tests for
carbon monoxide and cyanide were not performed.
TESTS AND RESEARCH
172RG
Evaluating the paint transfer marks on the 172RG wing root and the 172M horizontal stabilizer components, along with the radar provided ground speed of both
aircraft, it was possible to calculate the horizontal convergence angles and the collision angle between both airplanes. The airplanes converged at about a 50
degree angle relative to their longitudinal axes. The 172RG was traveling at about 102 knots, and the 172M was traveling at about 101 knots. Based on these
values the collision angle between the two airplanes was determined to be 80 degrees relative to the horizontal plane.
Cockpit Visibility
According to a Cessna representative, a left seated male with an average eye level height looking out the front windscreen has about 85 degrees visibility from
the center of his view to the right and 52 degrees from his center of view to the left. The pilot also has about 53 degrees of visibility from the center of vision
downward when looking out the left side window and 22 degrees from the center of vision downward when looking from the right window.
Other
FAA Regulations [14 CFR 91.113(b)] required that each person operating an aircraft maintain vigilance so as to "see and avoid other aircraft."
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07/16/2012 950 MDT
Regis# N5204K
Rockford, ID
Acft Mk/Mdl CESSNA 172N
Acft SN 17274009
Eng Mk/Mdl LYCOMING O-320-H2AD
Acft TT
Fatal
Opr Name: TETON LEASING LLC
Opr dba:
12692
0
Apt: Rockford Municipal Airport 2U4
Ser Inj
0
Aircraft Fire: NONE
Events
1. Enroute-cruise - Powerplant sys/comp malf/fail
Narrative
On July 16, 2012, at 0950 mountain daylight time, a Cessna 172N, N5204K, experienced a partial loss of engine power during level cruise flight. The pilot
subsequently initiated a forced landing in an open field, and came to rest inverted near Rockford, Idaho. The certified flight instructor and student pilot were not
injured. The airplane sustained substantial damage to the wings and the tail section. The airplane was registered to Teton Leasing, LLC, and operated by the
pilot under the provisions of 14 Code of Federal Regulations (CFR) Part 91 for the instructional cross-country flight. Visual meteorological conditions prevailed,
and a visual flight rules (VFR) flight plan was filed. The flight originated from Idaho Falls Regional Airport (IDA), Idaho Falls, Idaho, at 0835.
The flight instructor reported he had intended to conduct a cross-country flight from IDA to Arco-Butte County Airport (AOC), Arco, Idaho, into McCarley Field
Airport (U02), Blackfoot, Idaho, and back to IDA. The flight from IDA to AOC was uneventful. About 12 miles northwest of U02, the engine began to vibrate, and
the engine revolutions dropped to approximately 1,900 rpm. Carburetor heat was applied, the mixture was set to rich, and the fuel selector was in the BOTH
position. The airplane could not maintain altitude, and the flight instructor took control, and decided to divert for a landing at Rockford Municipal Airport (2U4),
Rockford.
Upon arrival at 2U4, the flight instructor determined the winds were calm, and elected to land on runway 16. During the landing sequence, the altitude and
airspeed were too high to safely land on the runway. He subsequently aborted the landing, and initiated a forced landing to a wheat field. During the touchdown,
the airplane collided with the wheat; the airplane's nose pitched down, and came to rest inverted.
A postaccident examination by a Federal Aviation Administration (FAA) inspector was conducted on the engine. The visual inspection of the engine revealed no
catastrophic failures; however, during the compression check, the numbers two and three cylinders had no compression. A closer inspection of the number
three cylinder revealed damage to the piston head, and the exhaust valve was not present. The intake tubes for the numbers two and three cylinders, as well
as, the exhaust system for the engine were removed. With the exhaust section removed, the FAA inspector was able to see the head of the missing valve
embedded into the cylinder head. The valve stem was missing and not located. Inspection of the number two cylinder revealed a large amount of metal dust
and debris in the intake and exhaust ports.
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07/16/2014 0
Acft Mk/Mdl CESSNA 172N-N
Regis# N737SY
Murphysboro, IL
Acft SN 17269650
Fatal
Opr Name: FLIGHTLINE
0
Ser Inj
Opr dba:
Apt: Southern Illinois MDH
0
Aircraft Fire: NONE
AW Cert: STN
Summary
According to a written statement from maintenance personnel, a pilot discovered the airplane's nose wheel at an "unusual angle" during a preflight inspection.
The pilot reported the damage to the fixed based operator (FBO) who asked maintenance to examine the airplane. Examination of the airplane revealed
damage to the nose wheel and underside of the fuselage aft of the main landing gear, and substantial damage to the rudder. The FBO contacted the certificated
flight instructors and pilots of the three flights that occurred preceding the damage report. The first and third flights were airplane checkout flights with the flight
instructor; the second flight was a personal flight conducted by a senior flight instructor. Written statements provided to the FBO from the two flight instructors
of those flights failed to reveal who was responsible for the damage, when or where it occurred, or how it was caused. Also unknown, is why the flight
instructors did not observe the damage prior to their respective flights.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: A hard landing by person(s)
unknown.
Events
1. Landing-flare/touchdown - Hard landing
1. Personnel issues-Action/decision-Action-Incorrect action performance-Not specified - C
Narrative
According to a written statement from maintenance personnel, a pilot discovered the airplane's nose wheel at an "unusual angle" during a preflight inspection.
The pilot reported the damage to the fixed based operator (FBO) who asked maintenance to examine the airplane. Examination of the airplane revealed
damage to the nose wheel and underside of the fuselage aft of the main landing gear, and substantial damage to the rudder. The FBO contacted the certificated
flight instructors and pilots of the three flights that occurred preceding the damage report. The first and third flights were airplane checkout flights with the flight
instructor; the second flight was a personal flight conducted by a senior flight instructor. Written statements provided to the FBO from the two flight instructors
of those flights failed to reveal who was responsible for the damage, when or where it occurred, or how it was caused. Also unknown, is why the flight
instructors did not observe the damage prior to their respective flights.
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Accident Rpt# ERA15CA196
04/17/2015 1400 EDT Regis# N66090
Sebastian, FL
Apt: Sebastian Municipal Airport X26
Acft Mk/Mdl CESSNA 172P
Acft SN 17275963
Eng Mk/Mdl LYCOMING O-320
Acft TT
Fatal
Opr Name: DELAND AVIATION
Opr dba:
14096
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Summary
The pilot stated that due to other traffic ahead in the airport traffic pattern, he purposely entered a high right base leg for runway 10, a 3,199-foot-long asphalt
runway. The airplane remained high during the approach and the pilot attempted to land on the last one-half of the runway; however, the airplane was also too
fast as the pilot had selected only 10 degrees of flap extension. The airplane subsequently touched down near the end of the runway, traveled over an
approximate 500-foot grass area beyond the end of the runway, and struck a fence before coming to rest upright. Examination of the airplane by a Federal
Aviation Administration inspector revealed substantial damage to the firewall. The inspector did not observe any preimpact mechanical malfunctions with the
airplane, nor did the pilot report any. The recorded wind near the accident site, about the time of the accident, was from 040 degrees at 7 knots.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's misjudged airspeed
and glidepath, which resulted in a landing area overshoot and runway excursion.
Events
1. Landing - Landing area overshoot
1. Personnel issues-Action/decision-Info processing/decision-Decision making/judgment-Pilot - C
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
Narrative
The pilot stated that due to other traffic ahead in the airport traffic pattern, he purposely entered a high right base leg for runway 10, a 3,199-foot-long asphalt
runway. The airplane remained high during the approach and the pilot attempted to land on the last one-half of the runway; however, the airplane was also too
fast as the pilot had selected only 10 degrees of flap extension. The airplane subsequently touched down near the end of the runway, traveled over an
approximate 500-foot grass area beyond the end of the runway, and struck a fence before coming to rest upright. Examination of the airplane by a Federal
Aviation Administration inspector revealed substantial damage to the firewall. The inspector did not observe any preimpact mechanical malfunctions with the
airplane, nor did the pilot report any. The recorded wind near the accident site, about the time of the accident, was from 040 degrees at 7 knots.
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04/30/2015 1155 PDT Regis# N65813
Acft Mk/Mdl CESSNA 172P-P
Acft SN 17275896
Los Angeles, CA
Rpt Status: Prelim
Fatal
0
Opr Name: GLENDALE COMMUNITY COLLEGE
Opr dba:
Page 48
Apt: Whiteman WHP
Ser Inj
Air Data Research
0
Prob Caus: Pending
Aircraft Fire: NONE
All Rights Reserved
Accident Rpt# WPR13FA211A 04/29/2013 1401 PDT Regis# N4677V
Calabasas, CA
Apt: N/a
Acft Mk/Mdl CESSNA 172RG
Acft SN 172RG0224
Acft TT
Fatal
Opr Name: AMERICAN FLYERS
Opr dba:
10383
2
Ser Inj
1
Aircraft Fire: NONE
AW Cert: STN
Events
1. Enroute-cruise - Midair collision
Narrative
HISTORY OF FLIGHT
On April 29, 2013 about 1401 Pacific daylight time, two airplanes, a Cessna 172RG, N4677V (172RG), and a Cessna 172M, N64030 (172M), collided in midair
approximately 3 miles southwest of Calabasas, California. The 172RG certified flight instructor and the commercial pilot sustained minor injuries, and the pilot
rated passenger sustained serious injuries; the airplane sustained substantial damage to the left wing. The 172RG was registered to AmeriFlyers of Florida,
LLC, and operated by American Flyers as a 14 Code of Federal Regulations (CFR) Part 91 instructional flight. The 172M commercial pilot and private pilot were
fatally injured, and the airplane was destroyed. The 172M was registered to a private party, and operated by the commercial pilot under the provisions of 14
CFR Part 91 as a personal flight. Visual meteorological conditions prevailed, and no flight plan was filed for either flight. The 172M departed from the Santa
Monica Municipal Airport (SMO), Santa Monica, California about 1313, and the 172RG departed from SMO about 1353.
The certified flight instructor (CFI) from the 172RG reported that the purpose of the flight was to familiarize two pilot rated students (one of which was seated in
the back seat) with the local airspace and normal practice areas. After departing SMO they flew north along the Santa Monica shoreline before proceeding to
the Malibu State Park and the Simi Valley practice area. As they crossed over Topanga Canyon, they switched from the SMO tower frequency to the local
practice area frequency and made the first position report transmitting "Malibu and Simi Valley practice area, white Cessna, over Topanga Canyon, northbound
at 2,800 climbing 3,500". They leveled off at 3,500 feet and the CFI asked the pilot in the right seat to perform the cruise checklist. The CFI made a second
radio call transmitting, "Malibu and Simi Valley practice area, white Cessna, over Calabasas, south of the 101, east of Malibu Canyon Road heading west
towards Westlake 3,500." No airplanes acknowledged their position reports nor did any other airplanes transmit a nearby position.
The pilot under instruction then conducted a right clearing turn from a westerly heading to a northerly heading and then brought the airplane back to the left and
leveled off on the original westerly heading. The CFI reported that he was looking to the front and the left in his normal traffic scan practice. When the airplane
had leveled off, he heard a loud bang and felt something hit the airplane on the left side. He looked outside at the left wing and noticed that the inboard leading
edge was damaged from the wing root outboard, the pitot tube was missing and the left wing strut was bent. The pilot's side window was also broken and metal
was protruding into the airplane. The CFI took control of the airplane and, unable to maintain altitude, executed a forced gear up landing onto a golf course. The
airplane slid about 430 feet when the left wing impacted a tree that spun the airplane about 180 degrees before it came to a rest.
A witness reported that he and his wife were walking in the area when they heard an extremely loud strike. He looked up and saw an airplane descending
almost vertically to the ground before it went out of his view; he did not note hearing an engine noise. Shortly after, he saw a plume of dark smoke rise from
where the airplane had disappeared. The witness further reported that his wife observed a second airplane depart the area to the west.
Review of the radar data revealed that the Cessna 172RG was observed on radar immediately after departure from SMO at 13:51:32 until shortly after the
collision occurred. At 14:01:04, the airplane's transponder return showed 3,500 feet mean sea level (msl) with a westerly track and a ground speed of 104
knots. At about 14:01:14 the track indicated the start of a gradual right 6 degree turn towards the northwest at a ground speed of 103 knots. At about 14:01:46
the airplane maintained a heading of 266 degrees until the collision occurred at 14:01:55 at 3,400 feet msl (about 2,540 feet above the ground). After the
collision, the airplane's track continued to the north followed by a left turn towards the west and a right turn to the northwest. The last radar return was at
14:02:32 at an altitude of 2,800 feet msl.
At 13:58:23 the Cessna 172M is identified on radar cruising in an easterly direction at 3,200 feet msl at 110 knots. At 13:59:00 the transponder return indicated
the airplane was at 3,200 feet msl and the track showed the start of a gradual left turn at 111 knots. At 14:01:09 the airplane was at 3300 feet msl, and at
14:01:28 the airplane was at 3400 feet msl flying at 100 knots. The collision occurred at 14:01:55. The airplane track made a sharp left turn and descended
rapidly into terrain.
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Cessna 172RG Flight Crew
The CFI, age 37, held an airline transport pilot certificate for airplane single- and multi- engine land issued December 22, 2012. The CFI also held a flight
instructor certificate for airplane single- and multi-engine land, which was issued February 19, 2012. His second-class airman medical certificate was issued on
May 11, 2012 with no limitations. The CFI had a total of 2,200 total flight hours, 600 of which were in the accident airplane make and model.
The pilot under instruction, age 34, held a commercial pilot certificate for airplane single- and multi- engine land issued on January 20, 2013. The second pilot's
first-class airman medical certificate was issued on November 20, 2012 with the limitation that he must wear corrective lenses. The second pilot reported 485
total flight hours; the accident flight was his first flight in the accident airplane make and model.
Cessna 172M Flight Crew
The first pilot, age 69, held a commercial pilot certificate for airplane single-engine land issued on October 29, 2003. The pilot also held a flight instructor
certificate for airplane single-engine land which was issued on July 25, 2011. The pilot's third-class airman medical certificate was issued on March 5, 2012,
with the limitation that she must wear corrective lenses. The pilot's logbook was not located. On the pilot's application for her most recent medical examination
she reported 1,750 total flight hours, 50 of which occurred within the six months preceding the examination.
The second pilot, age 63, held a private pilot certificate for airplane single-engine land issued May 10, 2010, and a certified airframe and powerplant mechanic
certificate issued on February 18, 2010. The pilot's third-class airman medical certificate was issued on December 6, 2011 with no limitations. On the pilot's
application for his most recent medical examination he reported 1,350 total flight hours, 25 of which occurred within the six months preceding the examination.
Cessna 172RG
The Cessna 172RG, serial number 172RG0224, was manufactured in 1980, and was a four seat, high wing airplane that was predominately white in color with
blue striping. The airplane was powered by a Lycoming O-360 series, 180 horsepower engine, and was equipped with a 2 blade McCauley propeller. The
airplane was registered to Ameriflyers of Florida LLC, and operated by American Flyers. The airplane's most recent maintenance was a 100 hour inspection
that occurred on April 5, 2013 at an airframe total time of 10,383.
Recovery personnel reported that during the recovery, about 43 gallons of fuel was removed from the fuel tanks.
Cessna 172M
The Cessna 172M, serial number 17264976, was manufactured in 1975, and was a four seat, high wing airplane that was predominately white in color with red
and blue striping. The airplane was powered by a Lycoming O-320 series, 180 horsepower engine, and was equipped with a 2 blade McCauley propeller. The
airplane was registered to a private individual and operated by the commercial pilot. Review of the maintenance records indicated that on April 16, 2013, at an
airframe total time of 5,862.3 hours, the airplane's engine and propeller were reinstalled onto the airplane from a previous incident involving a propeller strike.
The airplane's most recent annual inspection also occurred that day.
The nearest weather reporting station was located about 9 nautical miles northeast of the accident site at the Van Nuys Airport (VNY), Van Nuys, California. At
1351, VNY reported clear skies, wind 140 degrees at 6 knots, visibility 10 statute miles, temperature 17 degrees C, dewpoint 11 degrees C, and an altimeter
setting 29.82 inches of mercury.
COMMUNICATIONS
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The Federal Aviation Administration (FAA) reported that at 1313, the 172M pilot contacted Santa Monica air traffic control tower and requested to stay in the
pattern following maintenance. At 1340, the pilot requested a departure to the west. The controller approved the request, and terminated services.
At 1353, the 172RG pilot requested clearance to depart SMO to the west to follow the shoreline northbound. The request was approved and shortly thereafter
services were terminated.
There was no evidence of the two airplanes communicating with each other.
Cessna 172RG
The airplane landed onto the golf course hard and dug into the fairway grass. The grass and concrete showed sliding marks for about 430 feet along a bearing
of about 73 degrees magnetic, followed by a tree, and then the main wreckage. The main wreckage was orientated from tail to nose on a bearing of 253
degrees magnetic.
The airplane's left wing leading edge sustained two large indentations. One indentation was located at the wing root and was approximately three feet long.
Within the damaged wing root were distinct white and red diagonal paint transfer marks that were at about a 50 degree angle when compared to the nearest
longitudinal rivet line. The outboard dent was located about 2.5 feet from the wing tip and was about three feet long. Within the dent were brownish red scrape
marks as well as tree residue imbedded in the dent. The left strut sustained a dent approximately 2 feet from the bottom of the left wing. One of the propeller
blades had a one inch gouge along the leading edge about 6 inches from the propeller tip. The left side door posts were bent aft, and the upper portion of the
back center window post was bent to the right. The empennage remained intact and mostly undamaged.
About four pieces of right horizontal stabilizer and elevator with red and blue striping from the Cessna 172M were found on the ground resting near the left
horizontal stabilizer of the 172RG. Scratch marks were noted along the upper outboard portion of the largest horizontal stabilizer piece. These scratch marks
were measured to be at about a 50 degree angle when compared to the nearest longitudinal rivet line.
Cessna 172M
The wreckage of the 172M was located at an elevation of 1,170 feet on a mountain side about 5 miles southeast of Westlake Village, California.
The airplane impacted the ground in a nose low attitude and a postimpact fire ensued; the wreckage was heavily burned and no paint transfers or obvious
scratches from the collision were noted. The engine was separated from its engine mounts and the propeller was separated from the engine. The airframe
sustained forward accordion crushing throughout. The flap actuator was located and the flaps were in the up position. The flight control cables were traced
throughout the airframe and control continuity was established from the cabin controls to their respective flight control surfaces. The right horizontal stabilizer
and the elevator were separated from the forward horizontal stabilizer spar about 6 inches from the spar root. A small portion, which was believed to be the
inboard portion of the right horizontal stabilizer, was found within the wreckage. The remaining components of the right horizontal stabilizer and elevator were
not present on scene, however, they were found on scene with the 172RG.
Postaccident examination of the engine from the 172M revealed heavy thermal discoloration throughout. The cylinder rocker covers were removed; the valves
were intact and sustained thermal discoloration. The right magneto was separated from the engine, and the left magneto remained attached. The ignition leads
were consumed by fire. The spark plugs were removed and exhibited wear consistent with "Worn Out - Normal" when compared to the Champion AV-27
check-a-plug chart. When viewed from the spark plug holes, the interior surfaces of the cylinders and piston heads revealed no signs of internal catastrophic
damage.
The autopsies of the pilots from the Cessna 172M were performed by the Los Angeles County Department of Coroner, Los Angeles, California.
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The first pilot's autopsy was conducted on May 1, 2013, and concluded that the cause of death was multiple traumatic injuries. Specimens from the autopsy
were sent to the FAA's Civil Aerospace Medical Institute (CAMI) in Oklahoma City, Oklahoma, and toxicological tests were performed. The results were
negative for ethanol and drugs in the pilot's liver or muscle; tests for carbon monoxide and cyanide were not performed.
The second pilot's autopsy was conducted on May 2, 2013, and concluded that the cause of death was multiple traumatic injuries. Specimens from the autopsy
were sent to the FAA's CAMI and toxicological tests were performed. The results were negative for ethanol and drugs in the pilot's liver or muscle; tests for
carbon monoxide and cyanide were not performed.
TESTS AND RESEARCH
172RG
Evaluating the paint transfer marks on the 172RG wing root and the 172M horizontal stabilizer components, along with the radar provided ground speed of both
aircraft, it was possible to calculate the horizontal convergence angles and the collision angle between both airplanes. The airplanes converged at about a 50
degree angle relative to their longitudinal axes. The 172RG was traveling at about 102 knots, and the 172M was traveling at about 101 knots. Based on these
values the collision angle between the two airplanes was determined to be 80 degrees relative to the horizontal plane.
Cockpit Visibility
According to a Cessna representative, a left seated male with an average eye level height looking out the front windscreen has about 85 degrees visibility from
the center of his view to the right and 52 degrees from his center of view to the left. The pilot also has about 53 degrees of visibility from the center of vision
downward when looking out the left side window and 22 degrees from the center of vision downward when looking from the right window.
Other
FAA Regulations [14 CFR 91.113(b)] required that each person operating an aircraft maintain vigilance so as to "see and avoid other aircraft."
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12/01/2012 1900 HST Regis# N3554Y
Acft Mk/Mdl CESSNA 172S
Acft SN 172S8956
Eng Mk/Mdl LYCOMING IO-360-L2A
Opr Name: KRALL JOSE H
Kahului, HI
Apt: Kahului Airport OGG
Fatal
1
Ser Inj
Opr dba:
0
Aircraft Fire: NONE
Summary
The noninstrument-rated pilot was conducting a personal interisland flight. According to air traffic control information, shortly after the airplane took off, an air
traffic controller observed that the airplane's radar track was not heading toward the pilot's intended destination. He asked the pilot if he still intended to land at
his original destination, and the pilot replied that he did. The pilot then reported that he was going to perform a 360-degree turn to track toward his intended
destination. However, the airplane's radar track showed that the airplane then made a descending left turn. Subsequently, radio and radar contact with the pilot
and airplane, respectively, were lost, andÿa search and rescue mission was initiated. Parts of the airplane were located, but the pilot and the majority of the
airplane were not found. During the flight, the pilot did not report any mechanical malfunctions or failures with the airplane that would have precluded normal
operation.Dark (moonless) night conditions prevailed for the flight. Weather information did not reveal the presence of any aviation weather hazards. The data
did identify the potential for broken cloud layers below 3,000 ft mean sea level in the area at the time of the accident. Further, weather radar imagery identified
light rain showers at ground level. The pilot's intended flightpath likely would have taken the airplane through or very close to the area of light rain; however, it
could not be determined how long the pilot might have operated the airplane in these conditions. It isÿlikely that the pilot became spatially disoriented after
flying over the ocean during dark night conditions with reduced visibility and subsequently failed to maintain airplane control.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The noninstrument-rated pilot's
spatial disorientation and subsequent failure to maintain airplane control while operating over water in dark night conditions with reduced visibility due to rain in
the area.
ÿ
Events
1. Maneuvering - Loss of control in flight
2. Maneuvering - Collision with terr/obj (non-CFIT)
1. Personnel issues-Psychological-Perception/orientation/illusion-Spatial disorientation-Pilot - C
3. Environmental issues-Physical environment-Terrain-Water-Contributed to outcome
4. Environmental issues-Conditions/weather/phenomena-Light condition-Dark-Effect on operation - C
5. Environmental issues-Conditions/weather/phenomena-Ceiling/visibility/precip-Rain-Effect on operation - C
6. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-(general)-Not attained/maintained - C
Narrative
HISTORY OF FLIGHT
On December 1, 2012, at 1900 Hawaiian standard time, a Cessna 172S, N3554Y, impacted the Pacific Ocean about 5 miles from Kahului Airport (OGG),
Kahului, Maui, Hawaii. The owner/pilot operated the airplane under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. The pilot, the
sole occupant, is presumed to have received fatal injuries. The airplane was substantially damaged. Night visual meteorological conditions prevailed for the
flight from OGG to Molokai Airport (MKK), Kaunakakai, Molokai, Hawaii. No flight plan had been filed.
According to the Federal Aviation Administration (FAA), the flight departed about 6 minutes prior to the accident. Shortly before the accident occurred, an Air
Traffic Control (ATC) specialist noted an erratic flight pattern and contacted the pilot. The pilot declined assistance and informed ATC that he planned to make
a right 360-degree turn and track inbound to the MKK VOR. The ATC specialist reported that instead of a right 360-degree turn, the airplane's radar track
showed a left descending turn and was then lost from radar. The FAA reported that the airplane's last known altitude was 700 feet.
The Coast Guard responded to the last known position and commenced search and rescue (SAR) efforts. The Coast Guard recovered a portion of one of the
landing gear, along with some interior airplane pieces; however, the main wreckage was not located. SAR efforts were suspended on December 3, 2012.
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The pilot, age 51, held a private pilot certificate with ratings for airplane single engine land. He held a third-class medical issued on January 26, 2012, with no
limitations. No personal flight records were located for the pilot. The National Transportation Safety Board investigator-in-charge (NTSB IIC) obtained the
aeronautical experience listed in this report from a review of the FAA airmen medical records on file in the Airman and Medical Records Center located in
Oklahoma City. The pilot reported on his most recent medical application dated January 26, 2012, that he had a total time of 785 hours with 50 hours logged in
the past 6 months.
The four-seat, high-wing, fixed-gear airplane, N3554Y, Cessna C172S, serial number 172S8956, was manufactured in 2001. It was powered by a Lycoming
IO-360-L2A 160-horsepower. No aircraft logbooks were located for the accident airplane.
METEOROLOGICAL CONDITIONS
Weather conditions reported by OGG, in the accident area were wind from 250 degrees at 7 knots, visibility was 10 statute miles, sky condition was scattered
clouds at 2,500 above ground level (agl), temperature 24 degrees, dew point 19 degrees, and an altimeter setting of 30.03 inches of mercury.
According to a specialists report, calculations made by the RAwindsonde Observation Program (RAOB) did not identify any levels of significant turbulence or
icing, and the freezing level was identified as 14,725 feet. There was a potential for broken to few cloud layers below 3,000 feet.
The Terminal Aerodrome Forecast (TAF) issued at 1325 forecasted for the accident time indicated wind from 360 degrees (true) at 6 knots, visibility greater
than 6 statute miles, few clouds at 5,000 feet agl, and a broken ceiling at 25,000 feet agl. The TAF issued at Kapalua Airport, Lahaina, Hawaii, located about 16
miles west of the airplane's last known position, at an elevation of 256 feet, forecasted for the accident time indicated wind from 290 degrees (true) at 6 knots,
visibility greater than 6 statute miles, few clouds at 4,500 feet agl, scattered clouds at 7,000 feet agl, and a broken ceiling at 25,000 feet agl.
The Area Forecast (AF) for the Hawaiian Islands issued at 1740 and valid until 0600 on December 2, 2012, reported isolated visibility of 5 statute miles with
haze below 6,000 feet within the area of Oahu to the Big Island. It also advised of scattered or broken ceiling from 20,000 to 25,000 feet msl. The AF directed
toward "Oahu Molokai Lanai and Maui and remainder of Big Island," advised of scattered clouds at 3,000 feet msl, scattered clouds or a broken ceiling at 4,000
feet msl, cloud tops to 7,000 feet msl, and isolated light rain showers with cloud bases at 3,000 feet msl possible.
There were no AIRMETs or SIGMETs issued for the Hawaiian Islands, to include the accident location. There were no pilot reports made below 10,000 feet in
the vicinity of the Hawaiian Islands within 3 hours of the accident time. A detailed report is attached to the docket for this accident.
According to the United States Naval Observatory Astronomical Applications Departments' sun and moon data, sunset was at 1744, and the end of civil twilight
was at 1808.
COMMUNICATIONS
Review of the ATC radar and communication tapes revealed that the pilot was attempting to fly from Maui to Molokai.
According to the tower controller at OGC, the pilot had requested a visual flight rules (VFR) clearance to depart the airport. Prior to taxiing to the active runway,
the pilot requested that the lights be turned up and the controller complied by increasing the intensity of the runway lights to step 3 and verified that that was the
intensity that the pilot wanted. After takeoff, the controller observed a normal climb out. The controller noticed that the accident airplane was about 2 miles
northwest of the field; it made a right turn and began a climb above 1,000 feet. The controller then observed on the radar that the airplane was at 1,500 feet and
had entered into a descent. The controller was able to see the airplane out of his window, but lost sight of the airplane in the darkness. According to the radar,
the airplane was 5 1/2 miles north-northwest of the airport, in a right turn at 500 feet before the radar target entered into a "coast" status. The controller
attempted to find the airplane via binoculars, and then looked back at the radar scope. He observed the pilot's tag pop up about 1/4 mile from the last observed
position proceeding westbound at 700 feet; the radar tag went into a coast status again about 6 miles north of the airport. The controller subsequently received
a call from Honolulu Control Facility (HCF), stating that they had lost radio and radar with the accident pilot and airplane. HCF queried whether or not the pilot
had come over to the tower frequencies. The tower controller broadcasted on the tower, ground, and clearance delivery frequencies, but received no reply from
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the pilot.
According to the HCF controller, the accident airplane had been radar identified about 4 miles northwest of OGG, and the pilot was instructed to resume his
own navigation and altitude. The controller noted that the airplane had turned northeast bound and was traveling away from his intended destination. The pilot
was asked to verify his destination, to which he replied requesting radar vectors. The controller asked where the pilot wanted radar vectors to, and if he wanted
an Instrument Flight Rules (IFR) clearance. The pilot declined the IFR clearance and stated that he was destined for Molokai Airport. When the controller asked
if the pilot was tuned into the Molokai VORTAC, the pilot asked for verification that the frequency was 1161.1. The controller stated that the correct frequency
was 116.1. The pilot was requested to report on course to Molokai, and that the radar track was northeast bound and that a 295- or 300-degree heading would
take him to the north side of the airport. The pilot reported that he was going to do a right 360-degree turn, to which the controller asked the pilot to verify his
intentions. The pilot did not respond, and radar contract was lost at 1900. The controller attempted to contact the pilot to no avail.
The controller reported that the pilot sounded clear and calm with no stress apparent during the radio transmissions. The last radar echo showed the accident
airplane in a left turn at 700 feet above the water.
The airplane dropped off radar about 2.5 miles north of Pa'ia, Maui, and about 7 nautical miles northwest of OGG. The airplane was under visual flight rules
(VFR).
The airplane and the pilot were not located. As a result, an autopsy and toxicology could not be performed.
According to the Federal Aviation Administration, during the pilot's last medical exam dated January 26, 2012, the pilot reported high blood pressure and kidney
stones. A review of the pilot's medical history indicated that the high blood pressure was controlled with medication and the history of kidney stones (resolved
issue) should not pose a hazard to flight safety.
On December 8, 2012, the right wheel and tire washed up on the Kailua Beach Park.
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Acft Mk/Mdl CESSNA 177B-B
Opr Name:
Page 56
05/04/2015 1400 EDT Regis# N1102C
Acft SN 17702674
Roxboro, NC
Apt: Person County TDF
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire: NONE
All Rights Reserved
05/13/2014 1430
Regis# N5281D
Nampa, ID
Acft SN 50179
Acft TT
Fatal
Opr Name: BRUCE LAPE
Opr dba:
6306
0
Apt: Nampa Municipal Airport MAN
Ser Inj
0
Aircraft Fire: NONE
Summary
The pilot reported that, after an uneventful approach to the runway, he conducted a tail-low, three-point landing in the tailwheel-equipped airplane. About 30 ft
into the landing roll, the airplane suddenly turned sharply right and ground looped. Subsequently, the landing gear collapsed, and the left wing impacted the
ground. Postaccident examination of the tailwheelÿrevealed that, although it wasÿheavily worn, it castered freely. No evidence of a mechanical malfunction or
failure of the tailwheel was found that would have precluded normal operation.
Cause Narrative
directional control during the landing roll, which resulted in a ground loop.
Events
3. Landing-landing roll - Ground collision
Narrative
On May 13, 2014, about 1430 mountain daylight time, a Cessna 180A, N5281D, sustained substantial damage to the left wing during a ground loop at the
Nampa Municipal Airport (MAN), Nampa, Idaho. The private pilot and one passenger were not injured. The airplane was owned and operated by the pilot under
the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed, and no flight plan was filed. The flight
originated from MAN at about 1415.
The pilot reported that after an uneventful approach to the runway, he landed the tailwheel equipped airplane in a tail low, three-point landing. About 30 feet into
the landing roll the airplane suddenly turned sharply to the right and ground looped. Subsequently, the landing gear collapsed and the left wing impacted the
ground.
Postaccident examination of the tailwheel by a Federal Aviation Administration inspector revealed the tailwheel was heavily worn; however, it castered freely,
and no anomalies were noted.
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02/11/2014 830 MDT
Acft Mk/Mdl CESSNA 182J
Regis# N300EM
Belen, NM
Acft SN 18257529
Fatal
Opr Name: DRIVING SUCCESS INC
0
Apt: Alexander Muni E80
Ser Inj
Opr dba:
0
Aircraft Fire: NONE
AW Cert: STN
Events
2. Enroute-climb to cruise - Fuel starvation
Narrative
Shortly after takeoff the airplane experienced an engine failure. The pilot made an off airport landing and struck a pole, substantially damaging the left wing. The
pilot obtained assistance from personnel at the airport, who delivered approximately 20 gallons of fuel to the scene and helped the pilot move the airplane to a
nearby road. The pilot subsequently took off from the road and flew to a different airport about eight miles away from the departure point. Approximately 14
gallons of fuel was drained from the airplane after landing. The airplane was subsequently refueled and flown back to the departure airport.
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05/03/2015 0 CDT
Acft Mk/Mdl CESSNA 182P
Opr Name: BAUMAN LINDA C
Regis# N6579M
Mulberry, TN
Acft SN 18263763
Acft Dmg: DESTROYED
Acft TT
Fatal
4881
1
Apt: N/a
Ser Inj
Opr dba:
Rpt Status: Prelim
0
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: STN
Events
Narrative
On May 3, 2015, at an unknown time, N6579M, a Cessna 182P single-engine airplane, was destroyed when it impacted terrain and livestock near Mulberry,
Tennessee. The certified private pilot was killed. The airplane was registered to and operated by the pilot. No flight plan was filed for the flight that originated at
Winchester Municipal Airport (BGF), Winchester, Tennessee, about 1430 central daylight time. Visual meteorological conditions prevailed for the personal flight
conducted under 14 Code of Federal Regulations Part 91.
Personnel based at Winchester Airport reported seeing the airplane depart around 1430. Radar coverage for the accident area was weak; however, a target
was observed traveling westbound from the airport toward the location of where the accident occurred. The target was first observed at 1430 at an altitude of
3,300 feet about 11 miles west of the airport. The target proceeded west-northwest until the data stopped about 1.9 miles east of the accident site at 1433. At
that time, the target was at an altitude of 2,895 feet.
The airplane collided with trees and terrain on a cattle farm. There were no witnesses to the accident and the airplane wreckage was located the flowing
morning by a ranch-hand at 0822.
An on-scene examination was conducted by the National Transportation Safety Board Investigator-in-Charge (NTSB IIC) on May 5, 2015. The airplane collided
with a stand of 70-foot-tall hackberry trees with its right wing tip before it impacted the ground, another stand of hackberry trees and four cows. The airplane
then traveled a short distance and came to rest in a cattle pond. All major components of the airplane were located at the accident site and there was no
evidence of in-flight or post-impact fire.
Both wings sustained extensive impact damage and separated from the airframe in two sections. These sections of the wings came to rest near the base of the
second stand of hackberry trees. This was also the area where the cattle were located. The right wing tip exhibited more aft crushing to the leading edge than
the left wing.
The main wreckage, which consisted of the cockpit, fuselage, empennage and tail control surfaces came to rest in the shallow cattle pond. The engine had
separated from the firewall. The main wreckage sustained extensive impact damage.
The cattle pond was drained and the wreckage was removed and taken to a salvage facility where a layout examination was conducted on May 6, 2015.
Examination of the airplane confirmed flight control continuity for all major flight control surfaces from the control surface to the cockpit. The elevator trim tab
actuator was overextended from impact forces and the flap actuator was in the fully retracted position. Both fuel caps for each wing were in place and secure to
their respective fuel ports. Numerous breaks in the fuel system between the engine and fuel tanks were observed due to impact. The fuel selector was in the
"both" position. The gascolator remained attached to the firewall and was disassembled. The bowl had some water and sediment from the cattle pond and the
fuel screen was absent of debris.
No mechanical anomalies were noted with the airplane that would have precluded normal operation at the time of the accident.
The engine sustained impact damage, with more of the damage being concentrated on the right side. The right side cylinders were crushed and the push rods
and rocker arms were distorted. As a result, the engine could not be rotated more than 45 degrees. However, when the engine was rotated, continuity to the
accessory gears was observed. The oil sump was pushed up into the bottom of the engine. It was removed so the camshaft could be exposed. The camshaft
was intact and no mechanical anomalies were noted. Both magnetos had separated from the accessory case. They were water-soaked and spark could not be
produced at the terminals; however, both units were disassembled and no mechanical anomalies were noted. The oil filter remained attached to the engine. It
was removed and opened to expose the filter. The filter was absent of any debris.
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The propeller governor also remained on the engine. It was removed and disassembled. No anomalies were noted.
The spark plugs were removed and exhibited normal wear.
Examination of the carburetor revealed the throttle/mixture lever and actuator pump moved freely.
The 2-bladed propeller had separated from the engine and was found near the wing sections. Both blades were loose in the hub. One blade exhibited leading
edge and front face gouging and scoring. The blade was bent aft and was curled at the tip. There were nicks in the trailing edge as well. The second blade
exhibited front-face and leading edge polishing, and was bent aft. A section of the blade-tip was missing.
No mechanical anomalies were noted with the engine that would have precluded normal operation at the time of the accident.
A handheld GPS was located in the wreckage and was sent to the NTSB Recorder Laboratory in Washington DC for further evaluation.
The pilot held a private pilot certificate for airplane single-engine land, and instrument airplane. Her last Federal Aviation Administration (FAA) Third Class
medical was issued on August 6, 2012, with no limitations. At that time, she reported a total of 200 flight hours.
Weather at Winchester Municipal Airport, at 1435, was reported as wind from 210 degrees at 5 knots, visibility 10 miles, clear skies, temperature 26 degrees
Celsius, dewpoint 7 degrees Celsius, and a barometric pressure setting of 30.13 inches of Hg.
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04/18/2015 915 CDT
Regis# N1558D
Independence, IA
Acft SN 7780
Eng Mk/Mdl JACOBS R755 A-2
Acft TT
Fatal
Opr Name: HEDEMAN, DONALD L.
Opr dba:
614
0
Ser Inj
Apt: Independence Municipal Airport KIIB
0
Aircraft Fire: NONE
AW Cert: STN
Summary
The pilot was landing on runway 36. After touching down, the airplane began a slow right turn. The pilot attempted to correct by applying left rudder and light
braking, but the airplane departed the right side of the runway, and was substantially damaged. The wind was from 100 degrees at 14 knots, gusting to 18
knots, which resulted in a 13.7 to 17.7 knot crosswind component, and a 2.5 to 3.2 knot tailwind component. Most light general aviation airplanes are limited to
a direct crosswind component of 15 knots.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's attempt to land in
strong crosswind conditions, resulting in his on-ground loss of control. Contributing to the accident was the crosswind that exceeded the crosswind limits of the
airplane.
Events
1. Personnel issues-Action/decision-Action-Incorrect action selection-Pilot - C
2. Environmental issues-Conditions/weather/phenomena-Wind-Crosswind-Contributed to outcome - F
Narrative
The pilot configured the airplane for a crosswind landing on runway 36 using cross controlled inputs. He flared and touched down in a 3-point attitude. After
rolling 150 to 200 feet down the runway, the airplane began a slow right turn. He attempted to correct by applying left rudder and light braking, but the airplane
departed the right side of the runway. The left main landing gear was torn off, and the left wing was bent upward after striking the ground.
At the time of the accident, the wind was from 100 degrees at 14 knots, gusting to 18 knots. According to AeroPlanner.com "Wind Calculator and Wind Speed
Measurement," these conditions would result in a 13.7 to 17.7 knot crosswind component, and a 2.5 to 3.2 knot tailwind component. In the 1950s, maximum
crosswind components were not published by airframe manufacturers, but today light general aviation airplanes are limited to a direct crosswind component of
15 knots.
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Acft Mk/Mdl CESSNA 210J-J
Opr Name:
Page 62
01/14/2015 1012 CDT Regis# N3320S
Acft SN 21059120
Dodge City, KS
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire: NONE
All Rights Reserved
01/28/2015 300 CST
Regis# N131X
Rothville, MO
Acft Mk/Mdl CESSNA 310B
Acft SN 35239
Eng Mk/Mdl CONTINENTAL O-470
Acft TT
Fatal
Opr Name: TOMMY LEE KIRK
Opr dba:
5798
0
Apt: N/a
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STU
Events
1. Enroute-cruise - Fuel exhaustion
Narrative
The pilot reported that the airplane was at 8,000 feet mean sea level when it ran out of fuel. He executed a forced landing to a field which resulted in substantial
damage to the airplane. The pilot reported no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
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Accident Rpt# ANC15CA019
04/01/2015 1415 ADT Regis# N3885Q
Palmer, AK
Apt: Palmer Muni PAQ
Acft Mk/Mdl CESSNA A185F-F
Acft SN 18502207
Eng Mk/Mdl CONTINENTAL MOTORS IO-520D
Acft TT
Fatal
Opr Name: CRUZ DAVID C
Opr dba:
1020
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Summary
The pilot was landing to the south on a gravel runway in his tailwheel-equipped Cessna 185 airplane. During the landing rollout, a wind gust from the east was
encountered and the pilot was unable to maintain directional control. The airplane entered a ground loop, sustaining substantial damage to the right wing. The
pilot stated there were no preaccident mechanical malfunctions or anomalies 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 landing, resulting in a collision with terrain.
Events
1. Landing - Loss of control on ground
Narrative
The pilot was landing to the south on a gravel runway in his tailwheel-equipped Cessna 185 airplane. During the landing rollout, a wind gust from the east was
encountered and the pilot was unable to maintain directional control. The airplane entered a ground loop, sustaining substantial damage to the right wing. The
pilot stated there were no preaccident mechanical malfunctions or anomalies with the airplane that would have precluded normal operation.
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02/23/2014 1405 MST Regis# N18DP
Bountiful, UT
Apt: Skypark Airport BTF
Acft Mk/Mdl CESSNA P210N
Acft SN P21000086
Eng Mk/Mdl CONT MOTOR TSIO520P (1B)
Acft TT
Fatal
Opr Name: HOLT JACKY JR
Opr dba:
4500
0
Ser Inj
0
Aircraft Fire: NONE
Summary
The pilot reported that the accident flight was the first flight in the airplane since its annual inspection, which occurred about 6 weeks before the accident. He
conducted a thorough preflight inspection and run-up. Before takeoff, he added full power with the brakes applied, and, after noting no abnormal engine or
instrument indications, he took off.ÿWhen the airplane reached about 150 to 200 ft above the ground, the engine started to run roughly. The airplane was
unable to maintain altitude, so the pilot executed a forced landing to a nearby field.ÿDuring the landing, the airplane sunk into the mud and nosed over.
Postaccident examination of the engine revealed that the fuel lines connected to the input and output of the fuel flow indicator were loose and leaking. After
these lines were tightened about 1.5 turns and pressure was applied, a third leak was found in the vicinity of a metal label on the fuel line between the fuel
manifold and the fuel pressure gauge.ÿThe aircraft manufacturer's service manual states that the engine compartment rubber hoses must be replaced every 5
years or at engine overhaul, whichever occurs first. According to the airplane's maintenance logbook, the most recent engine overhaul occurred about 18 years
before the accident. The mechanic who conducted the annual inspection reported that, during the inspection, he removed the fuel lines to and from the
engine-mounted fuel flow transducer to troubleshoot a lack of indicated fuel pressure at the cockpit-mounted instrument. It is likely that the mechanic failed to
adequately tighten the fuel lines when he reinstalled them.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: Fuel starvation due to the
in-flight loosening of the fuel lines attached to the fuel flow indicator as a result of inadequate maintenance.
Events
1. Initial climb - Fuel starvation
3. Initial climb - Off-field or emergency landing
4. Landing - Nose over/nose down
1. Aircraft-Aircraft power plant-Engine fuel and control-Fuel flow indicating-Incorrect service/maintenance - C
2. Personnel issues-Task performance-Maintenance-Installation-Maintenance personnel - C
3. Aircraft-Fluids/misc hardware-Fluids-Fuel-Not specified - C
4. Aircraft-Aircraft handling/service-Maintenance/inspections-Time limits-Not serviced/maintained
Narrative
On February 23, 2014, about 1405 mountain standard time, a Cessna P210N, N18DP, experienced a loss of engine power shortly after takeoff from Skypark
Airport (BTF), Bountiful Utah. The pilot, the sole occupant, was not injured, and the airplane sustained substantial damage to the left wing and empennage. The
airplane was registered to, and operated by, private parties under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual
meteorological conditions prevailed, and no flight plan was filed. The airplane was destined for Heber City Municipal Airport - Russ McDonald Field (36U),
Heber Utah.
The pilot reported that this was the first flight after the airplane's annual inspection. He conducted a thorough preflight inspection and run-up. Before takeoff, the
pilot added full power with the brakes applied. The pilot listened to the engine and watched the instrument gauges; with everything operating normally, he took
off. When the airplane reached about 150-200 feet above the ground the engine started to run rough. Unable to maintain altitude, the pilot executed a forced
landing onto a nearby field. During the landing, the airplane sunk into the mud and nosed over.
During a postaccident examination by a Federal Aviation Administration inspector and a representative from Continental Motors, fuel pressure was applied to
the fuel lines from the left wing fuel tank to the engine. It was noted that the fuel lines connecting to the input and output from the JPI fuel flow Indicator were
loose and leaking. The lines were tightened at least 1.5 turns and pressure was reapplied to the fuel system. The leaks stopped, however, a third leak was
found in the vicinity of a metal label on the fuel line in between the fuel manifold and the fuel pressure gauge. The label indicated that it was installed by Cessna
during the fourth quarter of 1977.
The Cessna Model P210 Service Manual states "Replace engine compartment rubber hoses every 5 years or at engine overhaul, whichever occurs first." The
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airplane's engine was last overhauled June 20, 1996.
The airplane's maintenance logbook indicated that during the annual inspection that occurred on January 12, 2014, at a tachometer time of 547.07 hours,
"Wiring repaired on intercooler temperature probes, and FS-450 fuel scan miniature D connector (JPI fuel flow indicator)." Through email conversation, the
mechanic reported that during the annual inspection he removed the fuel lines to and from the engine mounted fuel flow transducer to troubleshoot a lack of
indicated fuel pressure at the cockpit mounted instrument.
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03/05/2015 1415 PST Regis# N8905R
Upland, CA
Apt: Cable CCB
Acft Mk/Mdl CHAMPION 7EC-NO SERIES
Acft SN 7EC-712
Eng Mk/Mdl CONTINENTAL MOTORS C90
Acft TT
Fatal
Opr Name: CABLE AIRCRAFT COMPANY INC
Opr dba:
2295
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Summary
The certificated pilot was receiving tailwheel instruction and stated he was practicing touch-and-go landings. On his seventh landing, the airplane went to the
right of the center line and he overcorrected. The flight instructor took the controls of the airplane. The right wing struck the ground and the airplane departed
the runway to the left. The airplane subsequently ground looped which resulted in substantial damage to the right wing.
The pilot reported no pre-impact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation.
Cause Narrative
directional control during landing.
Events
1. Landing - Loss of control on ground
Narrative
The certificated pilot was receiving tailwheel instruction and stated he was practicing touch-and-go landings. On his seventh landing, the airplane went to the
right of the center line and he overcorrected. The flight instructor took the controls of the airplane. The right wing struck the ground and the airplane departed
the runway to the left. The airplane subsequently ground looped which resulted in substantial damage to the right wing.
The pilot reported no pre-impact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation.
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05/10/2015 1200 PDT Regis# N6096F
Acft Mk/Mdl CHAMPION 7ECA-NO SERIES
Opr Name: MOORE PATRICIA A
Page 68
Acft SN 7ECA-352
Quincy, WA
Apt: Quincy Muni 80T
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire: NONE
All Rights Reserved
03/09/2015 1230
Regis# N949WB
Hurricane, UT
Apt: General Dick Stout Field 1L8
Acft Mk/Mdl CIRRUS DESIGN CORP SR22-NO SERIES Acft SN 0447
Eng Mk/Mdl CONT MOTOR IO-550 SERIES
Acft TT
Fatal
Opr Name: BANKS WES J
Opr dba:
2550
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Summary
The pilot reported that he entered a right traffic pattern for runway 19; on his first approach he noted that he was going to overshoot the runway and executed a
go-around procedure. On his second attempt after he touched down on the runway, he reported a "radical" right quartering tail wind that pushed the airplane to
the left of the runway. The airplane's left main tire departed the asphalt surface, the pilot then attempted a go-around by advancing the throttle to full and
decreasing the flaps to 50 percent. The pilot stated that he was not gaining lift and the stall warning horn was audible. Subsequently the airplane impacted a
ditch and bounced about 10 feet which resulted in substantial damage to the spar carry-through on the bottom of the fuselage.
The pilot reported there were no pre-impact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation.
Cause Narrative
directional control during the landing roll.
Events
3. Landing-aborted after touchdown - Collision with terr/obj (non-CFIT)
Narrative
The pilot reported that he entered a right traffic pattern for runway 19; on his first approach he noted that he was going to overshoot the runway and executed a
go-around procedure. On his second attempt after he touched down on the runway, he reported a "radical" right quartering tail wind that pushed the airplane to
the left of the runway. The airplane's left main tire departed the asphalt surface, the pilot then attempted a go-around by advancing the throttle to full and
decreasing the flaps to 50 percent. The pilot stated that he was not gaining lift and the stall warning horn was audible. Subsequently the airplane impacted a
ditch and bounced about 10 feet which resulted in substantial damage to the spar carry-through on the bottom of the fuselage.
The pilot reported there were no pre-impact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation.
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04/27/2015 1524 CDT Regis# N248ME
Sylacauga, AL
Apt: Merkel Field Sylacauga Muni SCD
Acft Mk/Mdl DIAMOND AIRCRAFT IND INC DA 20 C1
Acft SN C0267
Rpt Status: Prelim
Eng Mk/Mdl CONTINENTAL IO-240-B17B
Acft TT
Fatal
Opr Name: FALCON AVIATION ACADEMY
Opr dba:
4060
0
Ser Inj
0
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: STU
Events
Narrative
On April 27, 2015, at 1524 central daylight time, a Diamond Aircraft Industries DA20-C1, N248ME, was substantially damaged during a forced landing while
attempting to depart from Sylacauga Municipal Airport (SCD), Sylacauga, Alabama. The student pilot was not injured. Visual meteorological conditions
prevailed, and a company flight plan was filed for the flight, which was destined for Newnan Coweta County Airport (CCO), Newnan, Georgia. The instructional
flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.
The purpose of the flight was for the student pilot to complete a solo cross country flight. On the morning of the flight, the student met with his flight instructor to
review his flight plan and perform a preflight inspection of the airplane. They then filled the airplane's fuel tank with fuel and the student departed the airplane's
home base at CCO enroute to SCD. The flight instructor subsequently departed CCO in another airplane, and remained in radio contact with the student
throughout the uneventful flight.
Prior to departing on the return leg of the flight, the student pilot performed another preflight inspection of the airplane and runup check of the engine, and then
departed for CCO. The student initiated a takeoff from runway 9, and upon reaching an altitude of about 300 feet agl, he noted that the engine felt "bumpy" and
the airplane's climb performance had degraded. He responded by confirming that the mixture control was set to the fully forward position, the fuel pump was on,
and the throttle was fully open. The student then advised his flight instructor via radio of the engine issue. The flight instructor advised the student to again
ensure that the mixture was fully rich and that the fuel pump was on. About this time the engine rpm began decreasing from 2,300 rpm to 2,000 rpm. The
student again advised the flight instructor of the situation, and the flight instructor then told the student to return to the airport and land.
The student climbed the airplane to an altitude of about 900 feet agl, and while on the downwind leg of the traffic pattern noted that there was a helicopter in the
vicinity of the runway 9 approach end. Upon reaching the mid-field point of the downwind leg, the student reduced engine power to 1,800 rpm, and configured
the airplane for landing. At the mid-field point of the runway on final approach, the airplane was still "too high," and the flight instructor advised the student to
abort the landing and initiate a go-around. The student then positioned the throttle fully forward, retracted the flaps to the takeoff position, and attempted to
climb the airplane. After hearing the stall warning, the student decreased the airplane's pitch attitude, and performed a forced landing to a grassy area ahead.
During the landing, the right wing struck a utility line and the airplane landed hard, collapsing the nose landing gear, and resulting in substantial damage to the
firewall and forward portion of the fuselage.
A Federal Aviation Administration inspector examined the airplane at the accident site and oversaw a test run of the airplane's engine. During the test run, the
engine started normally, and due to damage sustained to the propeller, was run at a low power setting. The test was subsequently discontinued and the engine
and airframe were retained for further examination.
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Accident Rpt# WPR15LA154A 04/24/2015 1200 PDT Regis# N309EF
Van Nuys, CA
Acft Mk/Mdl DIAMOND AIRCRAFT IND INC DA 20 C1-C1Acft SN C0262
Acft Dmg: MINOR
Fatal
Opr Name: AMVAL LLC
0
Ser Inj
Opr dba:
Rpt Status: Prelim
0
Prob Caus: Pending
Aircraft Fire: NONE
Events
1. Taxi - Ground collision
Narrative
On April 24, 2015, about 1200 Pacific daylight time, a Cessna 150M, N6211K, and a Diamond DA20, N309EF, sustained damage during a ground collision at
Van Nuys Airport (VNY), Van Nuys, California. The Cessna sustained substantial damage and the Diamond sustained minor damage. The private pilot and pilot
rated passenger of the Cessna, and the student pilot and certified flight instructor aboard the Diamond were not injured. Visual meteorological conditions
prevailed, and no flight plan was filed for either of the local flights, which were both conducted under the provisions of Title 14 Code of Federal Regulations Part
91.
According to the pilot of the Cessna, he was taxiing to the airport's run-up area via taxiway Alpha when he noted another aircraft at his 10 o'clock position
entering his pathway. He reported that he applied brakes; however, the two airplanes collided on the taxiway.
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05/31/2013 1310 EDT Regis# N176MA
Linden, NJ
Apt: Linden LDJ
Acft Mk/Mdl DIAMOND AIRCRAFT IND INC DA 20-C1
Acft SN C0345
Eng Mk/Mdl CONT MOTOR IO-240-B
Acft TT
Fatal
Opr Name: BEST-IN-FLIGHT
Opr dba:
1985
1
Ser Inj
1
Aircraft Fire: NONE
Events
Narrative
HISTORY OF FLIGHT
On May 31, 2013, about 1310 eastern daylight time, a Diamond Aircraft Industries Inc., DA20-C1, N176MA, was substantially damaged when it impacted the
ground, shortly after takeoff from the Linden Airport (LDJ), Linden, New Jersey. The flight instructor was fatally injured and a passenger was seriously injured.
Visual meteorological conditions prevailed and no flight plan had been filed for the local introductory instructional flight that was conducted under the provisions
of 14 Code of Federal Regulations Part 91.
The airplane was owned by a limited liability company, and operated by Best-in-Flight, a flight school based at LDJ.
A witness at LDJ reported that the airplane departed from runway 27, a 4,140-foot-long, asphalt runway. The airplane's takeoff roll was longer than other
DA-20s he was use to observing and it "struggled" to break ground and gain altitude. The airplane made a right turn at an estimated altitude of between 125 to
150 feet above the ground, and immediately started to lose altitude. It descended behind a building and he heard the pilot radio "mayday" over the airport's
common traffic advisory frequency, stating "plane going down." He was then informed by the pilot of another airplane that the airplane had crashed. He further
stated that while he could not hear the airplane's engine noise clearly because of a nearby highway, the engine noise was constant and he did not hear any
power interruptions until after the impact.
Another witness, the pilot of a Mooney M20K, was holding on the runway when he observed the accident airplane lift off about two-thirds down the runway. The
airplane's attitude was flat and it did not seem to be climbing. He began his takeoff roll shortly thereafter and while on the upwind climb, he noted the accident
airplane was below his altitude, heading northwest on a 45-degree angle from the runway about 200 to 300 feet above the ground. He heard the accident pilot
transmit "mayday-mayday-mayday" and announce either "engine trouble" or "engine out." He then heard the pilot say "turning back to the airport." He
immediately thought to himself that the airplane was too low to try to turn back to the airport and that the pilot should have continued straight and attempted to
land in one of the surrounding factory lots. He next observed the airplane heading back toward the airport. The airplane was in a nose high pitch attitude, when
it "stalled." The right wing dipped, the airplane descended, spun a quarter-turn and impacted railroad tracks.
During an interview with a Federal Aviation Administration (FAA) inspector, the passenger reported that the flight instructor told him that he had his feet on the
brakes during the takeoff roll, and to place his feet flat on the floor, which he did. After takeoff, the flight instructor told him that the engine "wasn't making
power." The flight instructor called "mayday" and was trying to return to the airport when the airplane suddenly impacted the ground.
Radar data provided by the FAA for the Newark Liberty International Airport, which was located about 5 miles northeast of the accident site revealed the
accident airplane departed runway 27, and made a right turn to the north before radar contact was lost about 1 minute after takeoff. The target identified as the
accident airplane did not climb above an altitude of 200 feet.
The airplane struck and came to rest on abandoned railroad tracks on the site of a former automotive factory about a 1/2-mile northwest of LDJ. The site
contained several deteriorated asphalt parking lots adjacent to the south-southwest side of the railroad tracks.
The flight instructor, age 58, held a commercial pilot and a flight instructor certificate, with ratings for airplane single-engine land and instrument airplane. His
most recent FAA second-class medical certificate was issued on August 6, 2012.
According to the owner of the flight school, the flight instructor was hired during February 2011 and maintained a fulltime schedule as bookings permitted. The
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flight instructor's total flight experience at the time of the accident was about 4,400 hours, which included about 640 hours in the same make and model as the
accident airplane. The flight school reported that the flight instructor had accumulated about 200 and 45 hours of total flight experience, which included about
160 and 35 hours in the same make and model as the accident airplane, during the 90 and 30 days that preceded the accident; respectively.
The two-seat, low-wing, fixed-gear, airplane, serial number C0345, was manufactured in 2005 and primarily constructed of carbon and glass fiber reinforced
polymer. It was powered by a Continental Motors Inc. IO-240-B, 125-horsepower engine, equipped with a two-bladed Sensenich wooden propeller. The airplane
was certified in the utility category by Transport Canada in accordance with Canadian Airworthiness Manual Chapter 523-VLA.
Review of maintenance records revealed that the airplane had been operated for about 1,985 hours since new, and 38 hours since its most recent
"100hr/annual" inspection, which was performed on May 10, 2013. At the time of the accident, the engine had been operated for about 2,180 total hours. It was
noted that the engine was disassembled, inspected, and repaired for a sudden stoppage during May 2008.
According to the airplane flight manual, the airplane's total fuel capacity was 24.5 gallons. According to the owner of the airplane and flight school, the airplane
was "topped-off" with fuel the night before and was flown without incident for 2.6 hours prior to the accident. The airplane consumed between 4.5 and 6.0
gallons per hour (gph); however, he noted that consumption was generally "closer to 4.5 gallons" during flight school operations.
The owner further reported that performing a weight and balance calculation was part of the preflight checklist and that weight and balance forms for the
airplane were available on tables in the flight school; however, flight instructors would normally ask passengers their weight and perform the weight and balance
calculation mentally.
A weight and balance calculation for the accident flight was performed utilizing an airplane weight and balance form specific to the accident airplane that was
available at the flight school. Based on the passenger's reported weight of 290 pounds and the flight instructor's weight during his most recent FAA medical
certificate of 235 pounds, the airplane was estimated to be about 30 pounds above its maximum takeoff weight of 1,764 pounds. The airplane's center of
gravity was within limits.
When asked if he would fly with a passenger that weighed about 290 pounds, the owner stated that he would not, and would use the opportunity to convince
the passenger to fly in the DA-40, which was equipped with a 180-horsepower engine.
The owner felt that the accident airplane was "overpowered" with its 125 horsepower engine. He also stated that he was aware that it was "very hot" at the time
of the accident and if the reported temperature at the airport was 93 degrees Fahrenheit (about 34 degrees C), it was likely over 100 degrees F on most of the
airport property.
Both cockpit seats were equipped with a four-point safety belt. Each seat was equipped with two inertia reels that were secured to the aft bulkhead for shoulder
restraint. The lap belts were connected via a quick release/spring loaded clip-type fitting which hooked to an attach point that was embedded in the floor of the
fuselage on their respective outboard sides, and to a center tunnel attach point on their respective inboard sides. Each quick release was secured with a cotter
pin. According to a representative of the aircraft manufacturer, at that time of certification, the airplane's seat and seat belt attachments were designed for a 9g
forward, 1.5g sideward load, and a 190 pound occupant.
The aircraft maintenance manual, maintenance practices 100 hour inspection checklist requirements included ".Examine the safety belts for general condition
and security of the metal fitting in the surrounding composite.."
The reported weather at LDJ, which was at an elevation of 22 feet mean sea level, at 1315, was: wind 220 degrees at 5 knots; visibility 10 statute miles; sky
clear, temperature 34 degrees Celsius (C); dew point 16 degrees C; altimeter 30.08 inches of mercury.
The estimated density altitude at LDJ at the time of the accident was about 2,200 feet mean sea level.
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WRECKAGE INFORMATION
All major portions of the airplane were accounted for at the accident site. The airplane was found upright, with the nose down about 45 degrees. The right wing
was displaced aft and folded underneath the fuselage. The empennage was separated about 4 feet forward of the rudder and was resting partially on the
ground.
Examination of the ailerons, elevator, and rudder control systems did not reveal any preimpact malfunctions. The flap actuator was found in the takeoff
position, and the elevator trim actuator was found in the neutral/takeoff position. An undetermined amount of fuel had leaked on the ground and additional fuel
was observed leaking from an area around the engine driven fuel pump, which was separated and impact damaged. Fuel samples obtained from the gascolater
and fuel tank sump were absent of contamination. The fuel shutoff valve was in the OPEN position. The mixture control linkage was continuous from the engine
to the cockpit. The throttle control linkage was connected at the engine; however, the rod end at the cockpit was impact damaged, bent, and broken.
The engine sustained significant impact damage and remained attached to the airframe primarily by linkages to the throttle quadrant. The lower front portion of
the crankcase was fractured consistent with impact with the ground. All of the cylinders remained attached to the crankcase. The oil filter, oil cooler, No. 2
cylinder rocker arms, and alternator No. 2 were separated from the engine. The right magneto remained attached. The left magneto was separated and
remained attached to the engine via ignition leads. The top spark plugs were removed and exhibited normal operating signatures in accordance with a
Champion aviation check-a-plug comparison chart. Their electrodes were intact and dark gray in color. The fuel pump drive coupling was intact and the drive
shaft rotated freely when turned by hand. All cylinders were inspected using a lighted borescope. The cylinder bores were free of scoring and no evidence of
hard particle passage was observed in the cylinder bore ring travel area. Suction and compression were obtained on all cylinders at the top spark plug holes
when the crankshaft was rotated by hand at the crankshaft flange.
The propeller hub remained attached to the engine. One propeller blade was fractured at the hub, and the second propeller blade was separated about 2 feet
outboard of the hub. Several small propeller blade fragments were observed scattered around the accident site.
Subsequent disassembly of the engine, which included bench testing of both magnetos, the fuel pump, throttle body, manifold valve and fuel nozzles did not
reveal any anomalies that would have precluded normal engine operation.
The left and right seatpans were attached to the aft cockpit bulkhead wall with seven screws (five along the top of the seatpan, and two screws on the bottom
forward edge of the seatpan). The left seatpan contained a fracture on the bottom of the pan under a leather insert, a fracture in the middle of the seatpan, and
a crushing damage on the inboard edge of the seatpan. The right seatpan contained a fracture along its outboard edge and a section of separated composite
material near the inboard forward corner. The left seat restraint system remained intact. The right seat outboard lap belt was found disconnected from its attach
point. The quick release hook was distorted and the cotter pin remained installed. [Additional information can be found in the Survival Factors Factual Report
located in the public docket.]
The complete right seat restraint system and portions of the left seat restraint system were subsequently removed and forwarded to the NTSB Materials
Laboratory, Washington, DC for further examination.
First responders reported that the flight instructor, who was seated in the right seat, was ejected from the airplane. He was located next to the wreckage and
was unresponsive.
An autopsy was subsequently performed on the flight instructor by the Union County Medical Examiner's Office, Westfield, New Jersey. The autopsy report
revealed the cause of death as "blunt impact injuries."
Toxicological testing was performed on the pilot by the FAA Bioaeronautical Science Research Laboratory, Oklahoma City, Oklahoma, with no anomalies
noted.
TESTS AND RESEARCH
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Examination of the occupant restraint system performed by an NTSB metallurgist revealed the left seat quick release hook was intact and not deformed. The
right seat quick release hook was bent out of the plane of the attachment and twisted. In addition, the hook closure latch was also distorted and deformed. The
combined deformations of the hook and latch were such that the spring closure on the latch did not function and the throat of the hook was open, which would
allow the hook to engage or disengage on the anchor with the properly installed cotter pin in-place. [Additional information can be found in the Materials
Laboratory Factual Report located in the public docket.]
A representative from Diamond Aircraft calculated the available engine power during the accident flight based on the airport elevation and the outside air
temperature, using flight test data to determine target manifold pressures and the average full power engine RPM. At an RPM of 2,500, and manifold pressures
of 27 and 28 inches of mercury, chart brake horsepower was 101.4 (approximately 81 percent power being produced) and 105.9 (approximately 84.7 percent
power being produced); respectively. The calculations represented a perfect operating engine and did not take into account engine wear, cylinder compression
losses, and fuel system setup conditions.
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09/06/2013 1754 EDT Regis# N3940H
Beaver Falls, PA
Apt: Beaver County Airport BVI
Acft Mk/Mdl ENGINEERING & RESEARCH 415-D
Acft SN 4641
Eng Mk/Mdl CONT MOTOR A&C75 SERIES
Acft TT
Fatal
Opr Name: FERREN LARRY
Opr dba:
2219
0
Ser Inj
0
Aircraft Fire: NONE
Events
2. Initial climb - Loss of engine power (total)
Narrative
On September 6, 2013, about 1754 eastern daylight time, an ERCO Ercoupe 415-D, N3940H, was substantially damaged during a forced landing near Beaver
County Airport (BVI), Beaver Falls, Pennsylvania. The airline transport pilot and passenger were not injured. The airplane was registered to and operated by a
private individual under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed and no
flight plan was filed. The flight was originating at the time of the accident and was destined for North Central West Virginia Airport (CKB), Clarksburg, West
Virginia.
According to the pilot, he had flown in from his home base earlier that day uneventfully. The pilot conducted a preflight before his return back to CKB and noted
no anomalies. After takeoff while climbing though 200 feet above ground level (agl) the engine "began to run rough." The pilot attempted to turn back towards
the airport and halfway through a 180-degree turn, the engine had a loss of total power. The pilot was unable to maintain altitude and executed a forced landing
to a field, resulting in substantial damage to both wings.
An examination of the engine assembly by a Federal Aviation Administration (FAA) inspector revealed no anomalies were noted within the induction, carburetor
and fuel systems. The airplane was equipped with a Continental C75 series 75-hp engine and according to the FAA inspector it flew approximately 60 hours
since the last inspection. The logbooks were not available for review by the NTSB. During the examination approximately 18 gallons of blue fluid, similar in
color to 100LL aviation fuel, was discovered in the header tank.
Further examination of the engine revealed that the number 3 exhaust valve was stuck in the open position and an engine run was not performed. No internal
engine damage was noted as a result of the stuck valve. Internal examination of the engine revealed that the valve train was intact and rotation of the
crankshaft by hand achieved valve train continuity and compression on cylinders number 1, 2 and 4. Examination of the magnetos revealed that spark was
obtained on all ignition leads. The top and bottom spark plugs were removed and it was noted that the numbers 2 and 4 cylinder spark plugs were carbon
fouled. The other spark plugs exhibited normal wear signatures when compared to the champion spark plug chart.
The number 3 cylinder was removed and an excessive amount of coking was noted on the mid-span of the bore of the valve guide. An examination of the
engine oil revealed that the oil was free of debris and the quantity was at the operational level.
A review of the Continental Motors safety bulletin (SB) M77-3 stated that "100LL was an acceptable alternative fuel and continued on to indicate that the
amount of tetraethyl lead in these higher grade fuels had increased the lead build up and fouling of spark plugs along with valve erosion incidents reported on
some lower compression engines. When using this fuel, exhaust valve sticking could result from lead salt accumulation in the lubricating oil. Under such
circumstances, an exhaust leak between the exhaust elbow flange and the exhaust port face was possible, which resulted in localized cylinder head
overheating and subsequent exhaust valve and guide distress." Further review of SB M77-3 revealed that it is recommended that regular 50 hour oil changes
be implemented to reduce such accumulation. No record of 50 hour oil changes were noted in the engine logbook book as stated by the FAA inspector. It was
also recommended that spark plugs should be rotated every 50 hours of operation and cleaning/rotation every 100 hours.
A review of the FAA chart, titled "Conditions Favoring Carb Ice Formation," indicated that with the ambient temperature and dew point, "serious icing at glide
power" was probable at the time of the accident."
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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
Summary
Witnesses reported that they observed the airplane flying at a low level through a river canyon-one witness stated it was following the canyon's contours-and
then colliding with a marked power line strung across the river. The airplane subsequently impacted the ground. Scratch marks from the wire were observed on
the left wing. First responders reported that the pilot was in the rear seat, which might have hampered his forward visibility and led to his failure to see the
power lines.ÿ
The toxicological report identified the presence of ramipril and atorvastatin in the pilot's urine; however, neither of these medications are impairing. The
toxicology testing also detected a very low level of morphine in the pilot's urine, which indicates that he had used a medication containing an opioid within a few
days of the accident. However, because it was no longer detectable in the blood, it is not likely that the pilot was impaired by the medication at the time of the
accident.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's improper decision to
conduct low-level maneuvering in a river canyon with power lines, which resulted in his failure to maintain clearance from the power lines.
Events
1. Maneuvering-low-alt flying - Low altitude operation/event
2. Maneuvering-low-alt flying - Loss of control in flight
3. Maneuvering-low-alt flying - Collision with terr/obj (non-CFIT)
1. Personnel issues-Psychological-Attention/monitoring-Monitoring environment-Pilot - C
3. Personnel issues-Action/decision-Info processing/decision-Identification/recognition-Pilot - C
4. Environmental issues-Physical environment-Object/animal/substance-Wire-Awareness of condition - C
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.
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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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09/01/2013 1800 PDT Regis# N102HA
Sisters, OR
Apt: Sisters Eagle Air 6K5
Acft Mk/Mdl FLIGHT DESIGN GMBH CTSW
Acft SN 07-06-21
Eng Mk/Mdl ROTAX 912ULS
Acft TT
Fatal
Opr Name: BERNATH DANIEL A
Opr dba:
383
0
Ser Inj
0
Aircraft Fire: NONE
Summary
The sport pilot was conducting a cross-country flight in the light-sport airplane, and he reported that he encountered strong headwinds during the flight.
Concerned that the airplane's fuel level may be low, he landed at a private airstrip a few miles before his intended destination. He checked the fuel levels and
estimated that there was enough fuel for about 30 minutes of flight. He chose to depart, and a few minutes after takeoff, the engine lost all power. He performed
a forced landing into a field just short of the destination airport. The airplane sustained substantial damage during the accident sequence, and the pilot was not
injured. Immediately following the accident, the pilot reported that the airplane did not have any mechanical malfunctions and that it ran out of fuel.
Postaccident examination did not reveal any evidence of a preimpact engine malfunction or failure. Both fuel tanks were found intact and did not appear to be
breached. The airplane's fuel system appeared to meet the light-sport airplane industry design standards for usable fuel, which are similar to the Federal
Aviation Administration standards for certified aircraft.
The pilot did not respond directly to multiple requests from the National Transportation Safety Board investigator-in-charge to answer questions regarding the
specific accident circumstances. Therefore, the accident conditions could not be fully established. However, the pilot did provide multiple written declarations
regarding the quantity of fuel on board at the time of departure from the private airstrip; these reports stated that between 3 and 4.5 gallons of fuel were in the
right tank and that no fuel was in the left tank. However, only 1 gallon of fuel was recovered from the right wing tank, and the left tank was found empty, which
was well below the Federal Aviation Regulations (FARs) minimum fuel requirements for flight, which state that "no person may begin a flight under visual flight
rules conditions unless there is enough fuel to fly to the first point of intended landing and.to fly after that for at least 30 minutes of flight." Regardless of the
pilot's written estimates of the fuel onboard, as noted previously, in his initial statement, he indicated that the airplane only had about enough fuel remaining for
30 minutes of flight, which was still not enough fuel to meet the FARs minimum fuel requirements, and, therefore, his decision to take off at that time was
improper. The design of the airplane's wing resulted in both the fuel sight gauge and the dipstick being prone to significantly misrepresenting the actual fuel
quantity when the airplane was not level. Therefore, it is possible that the pilot misinterpreted the actual fuel quantity before takeoff.ÿIn addition, he exhibited
poor decision-making by failing to land earlier in the flight for fuel even though he overflew at least four airports that had fueling facilities. The pilot appeared to
have accrued almost 300 hours of flight experience in the airplane since he purchased it about 2 1/2 years earlier. Therefore, he should have had adequate
knowledge about its systems and performance capabilities and known that the dipstick and sight gauge were prone to errors and that the airplane would need
more fuel to complete the flight.
A similar accident in the United Kingdom (UK) resulted in the airplane's UK type certificate holder issuing a service bulletin (SB) that recommended that both
sight gauges show fuel in flight and that a landing be performed if any gauge reads empty. The SB also warned that, with one tank empty, the flight can
continue provided no turbulence is encountered and the airplane is not flown in a sideslip condition such that fuel moves away from the tank outlet. The
airplane's US distributor has not issued an SB regarding flight with one fuel tank empty, and this issue is not addressed in any placards or aircraft operation
manuals; therefore, it is possible that the pilot did not realize the limitations of flying the airplane with one fuel tank empty.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's inadequate preflight
fuel planning and poor decision-making, which resulted in fuel exhaustion and the subsequent loss of engine power. Contributing to the accident was the lack of
documentation describing the limitations of the airplane's fuel system.
Events
1. Enroute-cruise - Fuel exhaustion
2. Enroute-cruise - Loss of engine power (total)
3. Landing - Off-field or emergency landing
4. Landing-flare/touchdown - Collision with terr/obj (non-CFIT)
1. Personnel issues-Task performance-Planning/preparation-Fuel planning-Pilot - C
3. Organizational issues-Development-Design-Design of document/info-Manufacturer
4. Aircraft-Fluids/misc hardware-Fluids-Fuel-Fluid level - C
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Narrative
HISTORY OF FLIGHT
On September 1, 2013, about 1800 Pacific daylight time, a Flight Design CTSW, N102HA, lost engine power and landed about 1/2 mile short of its intended
destination, Sisters Eagle Air Airport, Sisters, Oregon. The light sport airplane was registered to, and operated by, the pilot under the provisions of 14 Code of
Federal Regulations (CFR) Part 91. The airplane sustained substantial damage during the accident sequence, and the sport pilot was not injured. The personal
flight departed Whippet Field Airport, Sisters, at an unknown time. Visual meteorological conditions prevailed, and no flight plan had been filed.
The pilot provided a verbal statement to a deputy of the Deschutes County Sheriff's Office following the accident. He reported that earlier in the day he
departed from Coeur d'Alene, Idaho, en route to Sacramento, California, and that he encountered strong headwinds and low clouds during the flight.
Subsequently he landed at Whippet Field, a private dirt airstrip approximately 5 miles east of Sisters Eagle Air Airport to check the airplane's fuel levels.
Estimating that he had sufficient fuel for approximately 30 more minutes of flight, he departed. As he approached Sisters Eagle Airport the engine "sputtered"
and then stopped producing power. He stated that the engine then started again, but then stopped. The airplane then struck soft dirt, and according to the pilot,
it did not crash, but encountered an, "Off runway landing." He stated that the airplane did not have any mechanical problems, and that it ran out of fuel. He
further reported that he was renting the airplane, that it was owned by "World Adventure Series," and that the purpose of the flight was to transport a dog to its
new owner in California. In a subsequent correspondence with the NTSB investigator-in-charge (IIC) he listed himself as the airplane's owner.
Subsequent examination revealed that the airplane had sustained substantial damage to the firewall, forward cabin structure, and lower right fuselage.
The pilot did not submit a Pilot/Operator Aircraft Accident Report (NTSB Form 6120.1), or respond to multiple requests from the IIC for a phone interview.
In a subsequent correspondence, the pilot's attorney stated that during the flight the pilot encountered strong westerly headwinds, and was having trouble with
bright sun in his eyes, and as a result he experienced difficulty reading the instruments, especially the fuel gauge.
The NTSB IIC requested via email that the pilot answer a series of questions further explaining the accident circumstances. His attorney responded, stating
that the pilot had elected to deny the request, asking instead to refer to the circumstances described in the complaint the pilot had filed for damages against
Flight Design USA, et al, in the U.S. District Court.
The pilot held a sport pilot certificate; as such he was limited to flying during the hours of daylight. The certificate was issued on November 27, 2011.
AIRPLANE INFORMATION
The airplane was manufactured in 2007 by Flight Design GmbH, and imported into the United States that year. The pilot purchased the airplane from Flight
Design in August 2010, and then transferred ownership to the current owner (a trust located at his home address) in April 2011. According to documentation
provided by Flight Design, up until the pilot purchased the airplane in 2010, it had been a demonstration airplane and had accrued a total flight time of about 88
hours. The Hobbs hour meter indicated 382.9 hours at the accident site.
The airplane was powered by a Rotax 912ULS series engine, equipped with a Neuform 2-blade composite propeller. The airplane was equipped with a BRS
Aerospace emergency parachute recovery system, which had not been activated during the accident. The most recent documented inspection occurred on
November 10, 2012, and was for a condition inspection. At that time, both the airframe and engine had accrued a total flight time of 348.9 hours.
Aviation weather observation stations positioned along the route of flight reported similar weather conditions consisting of clear skies, visibility of 10 miles or
greater, and light winds.
The closest National Weather Service weather observation to the accident site was from Roberts Field Airport, Redmond, Oregon, located approximately 17
miles east of the accident site at an elevation of 3,080 feet. The airport had an Automated Surface Observation System, which at 1756 reported wind from 330
degrees at 6 knots, clear skies, and visibility of 10 miles. The next observation at 1856 indicated clear skies but with wind from 310 degrees at 11 knots gusting
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to 18.
The NWS had no advisories current for the route for any Instrument Flight Rules or mountain obscuration conditions, thunderstorms, icing, or any significant
turbulence at the time of any preflight weather briefing prior to departure.
The winds aloft forecast for the region indicated winds at 6,000 feet out of the west-southwest with velocities between 9 and 16 knots. At 9,000 feet, the winds
were generally out of the southwest, with velocities of between 12 and 31 knots.
According to the U.S. Naval Observatory, Astronomical Applications Department, the computed sunset occurred in Redmond, at 1940, with civil twilight ending
at 2010. At 1810, the sun was 15.6 degrees above the horizon at an azimuth of 265 degrees.
TESTS AND RESEARCH
Both wings were removed from the airplane, which was then recovered from the accident site, and examined on February 4, 2014, by the NTSB IIC, and
representatives from the FAA, Rotax Aircraft Engines, and Flight Design USA. As the state of manufacture, the German Federal Bureau of Aircraft Accident
Investigations (BFU) assigned a non-traveling accredited representative.
The fuel system was examined and was found to be free of obstructions. Both fuel tanks were intact and did not appear to be breached. The fuel caps were in
place, and both cap gaskets were intact and pliable, with the cap vents facing the correct direction. The fuel tanks were inspected internally and no debris,
contamination, or de-bonding was observed.
Examination of photographs taken at the accident site revealed a circular area of dust surrounding the right wing filler cap, along with a fluid-like streak of dust
emanating from the fuel cap and moving aft. Remnants of these signatures were still present during the examination. The photos indicated that the airplane
came to rest right-wing-low due to the collapse of the right main landing gear during the impact sequence. The direction of the fuel stain signatures were
consistent with a prior tank overfill event, rather than fuel leaking from the tank post-accident.
There was no evidence of pre-impact engine malfunction or failure, and following completion of the examination, the engine was started and operated
appropriately at various speeds. A complete examination report is contained within the public docket.
Fuel System Design
The CTSW airplane is equipped with two integral wing tanks, each with a capacity of 17 gallons (16.5 useable). The tanks are 57 inches long by 15 inches
wide, extending from the wing root, and positioned forward of the main spar. Fuel quantity is gauged visually within the cabin through a sight-tube located at
each wing root rib. Both wings have a dihedral angle of 2 degrees, and a rigid pickup tube with an integral strainer is located at the tank floor at each wing root.
Each tank contains a single baffle (anti-sloshing rib) located approximately 21 inches from the root. Fuel passes through the baffle via a series of holes at the
leading edge, upper spar cap, and when the fuel quantity is low, through a series of 5 and 8 millimeter holes adjacent to the tank floor. The fuel tanks are
vented through vented fuel caps located on the upper outboard surface of the wings. A calibrated dipstick with separate left and right tank increments is utilized
to check the fuel quantity when on the ground.
Fuel is fed by gravity down two fuel lines in the cabins A-columns; according to the CTSW Maintenance and Inspection Procedures Manual, the lines in the
A-columns are of larger volume, "to maintain fuel flow also in sideslip conditions with low fuel for a certain time". The two lines are connected at a T-fitting
located on the engine side of the firewall. From the T-fitting, fuel is routed back into the cabin, and through a fuel shutoff valve (on/off only) and fuel filter. The
fuel is then routed back through the firewall to the gascolator located adjacent to the lower section of the engine mount, and then onwards to an engine-driven
fuel pump.
The design allows fuel to be fed from both tanks simultaneously, and there is no provision for the pilot to make a fuel tank selection.
Fuel System Testing
Both wings were reattached to the fuselage, along with their respective fuel line fittings. The airplane was leveled both laterally and longitudinally and fuel
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(totaling 3.5 gallons per side), was incrementally added to each tank while simultaneously recording the levels utilizing both the cabin sight gauge, and the
Flight Design fuel quantity dipstick found in the airplane.
The dipstick quantity generally matched the tank quantity. The sight gauges, although prone to parallax error, were accurate to within 1 gallon. However, it was
noted that small changes of the airplane's bank angle resulted in large fluctuations in the quantity observed at the sight gauge; specifically, with 3.5 gallons of
fuel in the tanks, lowering the right wing 2 degrees resulted in the indicated fuel dropping to the 1-gallon level. Similar but reversed (due to the location of the
cap at the tip of the tank) values were observed at the dipstick for various bank angles.
Recovered Fuel Quantity
Recovery personnel reported draining about 1.5 gallons from the right wing tank during the recovery, and stated that the left wing tank was empty. They did not
observe fuel issue from either of the wing tank fuel lines during removal of the wings from the airframe. When questioned about the method utilized to gauge the
recovered fuel quantity, a recovery technician stated that it filled the lower 3 inches of a 5-gallon bucket. The examination group then filled the same bucket
with fuel to the 3-inch level and measured the quantity with a calibrated beaker, resulting in an observed total of 1 gallon and 4 ounces (1.03 gallons).
Fuel Records
Two fueling facilities were located at Coeur d'Alene Airport, and both were capable of supplying 100 low-lead aviation gasoline. Both facilities reviewed their
fueling records for the one week period leading up to the accident, and neither could locate records for the pilot or airplane during that period.
Whippet Field Airport was a private field comprised of a single turf airstrip. It did not have provisions for refueling. The airstrip was along the presumed route of
flight, and about 5.5 miles east of Sisters Eagle Air Airport.
The last 170 miles of the route of flight (assuming a heading of 230 degrees magnetic) would have passed within 10 miles of 17 airports, 4 of which had
refueling facilities.
Pilots Statement Regarding Fuel Quantities
The pilot and his attorney provided three separate submissions containing references to the fuel quantity onboard the airplane when it departed Whippet Field
Airport. The first included a statement written by the pilot, and signed presumably by a witness reporting that the witness observed the pilot check the fuel
quantity utilizing the fuel gauge dipstick, and that the right fuel tank contained 3 gallons of fuel (a separate notation of "over 3 gallons" was written in a different
typeface at the end of the sentence). A second document written by the pilot's attorney stated that 4.5 gallons of fuel was present in the right tank. A
subsequent email sent by the pilot stated that the airplane was carrying between 3 to 4 gallons of fuel in the right tank. All documents reported that the left tank
was empty.
CTSW Operating instructions
According to the CTSW Airplane Operating Instructions current for the airplane at the time of the accident, the airplane's fuel capacity was 17 US gallons per
tank, 16.5 of which is usable. The manual states that fuel is gravity fed, and that the fuel valve has two positions, either "on" or "off".
The engine can operate on both 100 low-lead aviation gasoline as well as premium automotive unleaded gasoline which meets American Society for Testing
and Materials (ASTM) D 4814 specifications, with a minimum anti knock index of 91. Fuel consumption at takeoff and "75% continuous performance" was 7.1
and 4.9 gallons per hour, respectively.
Flight Design discontinued production of the CTSW model in 2007, replacing it with a similar variant, the CTLS. The fuel system remained largely the same with
the exception that a return flow flapper valve was included on the fuel tank anti-sloshing rib. Additionally the tanks were interconnected with a vent line, and
each tank also vented to its respective wingtip. The CTLS Airplane Operating Instructions, Normal Operating Procedures (Cruise) section, denoted of the
following:
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"Warning: A correct indication on the fuel sight gages in the wing ribs is only possible when the aircraft is leveled.
Warning: There is a tendency to fly the CTLS-LSA with a small sideslip angle. Flight performance is only marginally affected but it can lead to the tanks
emptying at different rates. In this case, it is recommended to raise the wing with the fuller tank in a gentle temporarily slip. This can be achieved with the help
of the rudder trim, if installed. The aircraft should be returned to level flight after a few minutes and the fuel indication checked. The amount in the tanks should
now be more even.
Warning: The tanks in the CTLS have return flow flapper valves on the fuel tank anti-sloshing rib (refer to Chapter 7 Systems Description). They prevent fuel
from quickly flowing into the outer tank area during side slipping where it could not be fed into the engine. The return flow valve reduces but does not
completely prevent return flow. An exact indication of fuel quantity is thus only possible at the wing root when, after a sideslip, the aircraft has returned to
normal flight attitude (and the amount of fuel inside and outside the anti-sloshing rib has evened out)."
The CTSW flight manual did not contain similar verbiage, and neither the CTLS or CTSW manuals, nor any airplane placards or Flight Design USA safety
directives made any recommendation regarding flight with one fuel tank empty.
ASTM Standards
The CTSW airplane was designed to comply with the ASTM Consensus Standards, F2245, Revision 4 (Design and Performance of a Light Sport Airplane). The
standards make only one reference with regards to unusable fuel:
"7.3.1. The unusable fuel quantity for each tank must be
established by tests and shall not be less than the quantity at which the first evidence of engine fuel starvation occurs under each intended flight operation and
maneuver."
By comparison, aircraft certified under 14 CFR Part 23 (Airworthiness Standards: Normal, Utility, Acrobatic, and Commuter Category Airplanes) must meet the
following standards:
"23.959 (a) Unusable fuel supply. The unusable fuel supply for each tank must be established as not less than that quantity at which the first evidence of
malfunctioning occurs under the most adverse fuel feed condition occurring under each intended operation and flight maneuver involving that tank."
CTSW Accident in the United Kingdom
The United Kingdom Department for Transport Air Accidents Investigation Branch (AAIB) investigated an accident on August 12, 2009, involving a similarly
equipped CTSW airplane. The airplane experienced a fuel starvation event during the landing approach. It was subsequently determined that at that time, the
right tank was empty, and the left tank contained about 1.32 gallons of fuel.
Testing performed during that accident investigation established that with 1.32 gallons of fluid in the right tank, and the wing set to an angle of 8 degrees, the
sight gauge indicated that the tank was almost half full. Subsequent tests revealed that with the tank level, it continued to issue fluid at its outlet until only 0.132
gallons remained.
The investigation identified flight planning as a contributory factor and the AAIB issued a recommendation that, "Flight Design GmbH, together with P&M
Aviation (the CTSW type certificate holder in the UK), revise their assessment of the unusable fuel in the CTSW aircraft."
P&M Aviation subsequently issued Service Bulletin SB 131. The service bulletin did not make any revisions to the unusable fuel quantity as recommended by
the AAIB, but instead recommended a detailed series of actions with regard to monitoring fuel quantities, including the recommendation that both sight gauges
must show fuel in flight, and that a landing should be performed if any gauge reads empty. The service bulletin further stated, "if one tank should empty before
the other, in level flight the remaining fuel can still be used up....However, if the aircraft is in turbulence and/or the airplane is flown with sideslip putting the
outboard end of the feeding tank low, it is possible for the feed to be uncovered and air to be drawn into the system causing the engine to stop."
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Fuel Requirements
Federal Aviation Regulation 14 CFR 91.151, under Visual Flight Rules (VFR), "Fuel requirements for flight in VFR conditions" states in part, that no person may
begin a flight in an airplane under VFR conditions unless (considering wind and forecast weather conditions) there is enough fuel to fly to the first point of
intended landing and, assuming normal cruising speed during the day, to fly after that for at least 30 minutes.
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05/05/2015 1650 EDT Regis# N7089S
Acft Mk/Mdl HUGHES TH 55-NO SERIES
Opr Name:
Page 85
Acft SN 67-16817
Morganton, NC
Apt: Foothills Regional MRN
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire: NONE
All Rights Reserved
05/06/2015 1220 PDT Regis# N350BC
Acft Mk/Mdl ISSOIRE SIREN PIK 30-NO SERIES
Opr Name: ROLLIN HASNESS
Page 86
Acft SN 716
Spokane, WA
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire: NONE
All Rights Reserved
Accident Rpt# ERA15CA157
03/16/2015 1955 EDT Regis# N231KA
Acft Mk/Mdl MOONEY AIRCRAFT CORP. M20K-NO
Opr Name: PRIDGEN MICHAEL E
Page 87
Laurel, MD
Apt: Suburban W18
Acft SN 25-0005
Rpt Status: Prelim
Acft TT
Fatal
3562
0
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire: NONE
All Rights Reserved
07/14/2014 1220
Regis# N562BG
Durango, CO
Acft Mk/Mdl MOONEY AIRPLANE CO INC M20TN-NO
Acft SN 31-0031
Eng Mk/Mdl CONT MOTOR TSIO-550-G
Acft TT
Fatal
Opr Name: JOHN B HARRINGTON
Opr dba:
335
0
Apt: Durango-la Plata County DRO
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Summary
The pilot reported the airplane ballooned up after touchdown onto the runway. He applied "moderate power" to hold the airplane above the runway, while the
airspeed decreased and the airplane settled onto the runway again. When "moderate power" was applied, the airplane climbed and the stall warning horn
sounded. The pilot applied full power to go-around. The airplane banked left off the runway, bounced 2 to 3 times and came to rest on the opposite side of the
parallel taxiway. The airplane sustained substantial damage to the left wing.
Cause Narrative
control during landing.
Events
1. Landing-flare/touchdown - Loss of control in flight
1. Personnel issues-Action/decision-Action-Incorrect action performance-Pilot - C
Narrative
The pilot reported the airplane ballooned up after touchdown onto the runway. He applied "moderate power" to hold the airplane above the runway, while the
airspeed decreased and the airplane settled onto the runway again. When "moderate power" was applied, the airplane climbed and the stall warning horn
sounded. The pilot applied full power to go-around. The airplane banked left off the runway, bounced 2 to 3 times and came to rest on the opposite side of the
parallel taxiway. The airplane sustained substantial damage to the left wing.
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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
Summary
The pilot and passenger departed on the flight in a vintage warbird airplane. After departure, radar tracked the flight along a bay in a southwestern direction. A
witness reported that he heard the airplane overhead heading south and that he then saw the airplane slowly turn north and appear to descend at a high rate of
speed before it impacted the water. The airplane was largely fragmented upon impact.
The flight was recorded by an onboard video recording system. A review of the video revealed that, a few minutes into the flight, the pilot asked the passenger
if he'd like to fly the airplane. The passenger replied he was not a pilot, but he'd like to try it. The video showed that, with the passenger at the controls, the
airplane steeply banked right to about 90 degrees, and the nose dropped; the pilot explained that back pressure was needed on the stick during turns to prevent
the loss of lift. The conversation continued as the airplane was rolling to wings level and as the pilot was encouraging the passenger to pull back on the stick.
During this time, the video showed the airplane descending toward the water. Neither the pilot nor passenger acknowledged the impending collision. It is likely
that the pilot's focused attention on instructing the passenger contributed to the his lack of recognition of the impending collision. It could not be determined if
the water's smooth surface contributed to the pilot's loss of situational awareness. The accident is consistent with the pilot's loss of situational awareness
resulting in controlled flight into the water.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's loss of situational
awareness while instructing the passenger, which resulted in the controlled flight of the airplane into the water.
Events
1. Enroute - Controlled flight into terr/obj (CFIT)
1. Personnel issues-Psychological-Perception/orientation/illusion-Situational awareness-Pilot - C
3. Environmental issues-Physical environment-Terrain-Water-Awareness of condition - C
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.
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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
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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05/18/2014 1200
Acft Mk/Mdl NORTH AMERICAN SNJ 6-6
Regis# N5485V
Santa Fe, NM
Acft SN 112007
Fatal
Eng Mk/Mdl P&W R1340 SERIES
Opr Name: SYMINGTON MANAGEMENT SERVICES
LLC
0
Apt: Santa Fe Muni SAF
Ser Inj
Opr dba:
0
Aircraft Fire: NONE
AW Cert: STN
Summary
The pilot had planned an overhead traffic pattern, which provided for better visibility when he sat in the rear seat. While on downwind the pilot was directed to
extend downwind and fly a straight-in approach. The pilot accepted the instructions, knowing his visibility for landing would be restricted and he would likely
have to drop the nose of the airplane on approach to see forward during landing. The pilot landed "a bit fast" after dropping the nose, and a light crosswind
possibly pushed the airplane right. The pilot over corrected to the left and added power to go around. The airplane skidded left and exited the runway, causing
the right main gear to collapse and the right wing and prop to strike the ground. In his statement, the pilot did not indicate there was any malfunctions with the
airplane prior to the accident.
Cause Narrative
control during landing and subsequent go around attempt.
Events
1. Approach-VFR pattern final - Loss of visual reference
2. Approach-VFR pattern final - Other weather encounter
3. Landing-flare/touchdown - Loss of control in flight
4. Landing-flare/touchdown - Runway excursion
1. Aircraft-Aircraft structures-Windows-windshield system-(general)-Design - F
2. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Airspeed-Not attained/maintained - F
3. Environmental issues-Conditions/weather/phenomena-Wind-Crosswind-Ability to respond/compensate
Narrative
The pilot had planned an overhead traffic pattern, which provided for better visibility when he sat in the rear seat. While on downwind the pilot was directed to
extend downwind and fly a straight-in approach. The pilot accepted the instructions, knowing his visibility for landing would be restricted and he would likely
have to drop the nose of the airplane on approach to see forward during landing. The pilot landed "a bit fast" after dropping the nose, and a light crosswind
possibly pushed the airplane right. The pilot over corrected to the left and added power to go around. The airplane skidded left and exited the runway, causing
the right main gear to collapse and the right wing and prop to strike the ground. In his statement, the pilot did not indicate there was any malfunctions with the
airplane prior to the accident.
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Accident Rpt# ANC15CA025
Acft Mk/Mdl PIPER PA 18-150
Opr Name: GRAHAM, JASON
Page 92
05/14/2015 1809 UTC Regis# N2998P
Acft SN 18-4514
Anchorage, AK
Apt: Lake Hood LHD
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire: NONE
All Rights Reserved
08/22/2014 1554 CDT Regis# N8440N
New Orleans, LA
Apt: Lakefront NEW
Acft SN 28-8216003
Eng Mk/Mdl LYCOMING O-320-D3G
Acft TT
Fatal
Opr Name: ROBERT E BRASWELL
Opr dba:
5687
0
Ser Inj
0
Aircraft Fire: NONE
Events
1. Approach - Loss of engine power (total)
Narrative
On August 22, 2014, at 1554 central daylight time, a Piper PA 28-161 airplane, N8440N, ditched into Lake Pontchartrain near the Lakefront Airport (NEW), New
Orleans, Louisiana. The pilot, who was the sole occupant, was not injured. The airplane sustained substantial damage. The airplane was registered to and
operated by a private individual under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed
at the time of the accident and the flight was operated on a visual flight rules flight plan. The airplane departed the Jack Brooks Regional Airport (BPT),
Beaumont/Port Arthur, Texas, at 1353 and was enroute to NEW.
The pilot stated that he departed BPT with about 17 gallons of fuel in the left tank and 24 gallons in the right tank. He departed with the right fuel tank selected
and switched fuel tanks every 30 minutes during the flight. The flight was uneventful until the descent from 1,500 feet above ground level (agl) when the engine
experienced a total loss of power. He attempted to restart the engine multiple times without success. He was cleared to land on runway 09, but the airplane
was unable to glide to the runway. The pilot ditched the airplane into Lake Pontchartrain a quarter mile west of runway 09's threshold. The pilot egressed from
the airplane and swam to shore. The airplane sank into the lake.
The responding Federal Aviation Administration (FAA) inspector stated that the airplane was removed from the lake and placed inverted on a barge. He
observed fuel leaking from the right wing. A postaccident examination revealed that the engine's crankshaft gear retaining bolt was separated at the head. The
lockplate did not appear to be bent or out of place.
The crankshaft gear, gear retaining bolt, and associated lockplate were sent to the NTSB Materials Laboratory, in Washington, D.C. for examination. The exam
revealed that the bolt fractured at the fillet radius between the shank and the head. Examination of the fracture surfaces with a field emission scanning electron
microscope (FE-SEM) revealed very fine fatigue striation features within the fracture surfaces.
The inner surfaces of the counterbore on the crankshaft gear exhibited areas of fretting wear and polishing wear scars. A defined fretting wear scar was noted
partially around the circumference of the bolt through-hole.
The lockplate exhibited areas of fretting wear and polishing wear scars. The lockplate's retention tab was in the open position and did not exhibit typical
mechanical deformation associated with bending to the closed position (e.g. 90ø position). Defined circumferential fretting wear scars were noted partially
around the circumference of the bolt through-hole.
According to Lycoming Service Bulletin (SB) 375 Revision C, January 30, 2003, "Damage to the crankshaft gear and the counterbored recess in the rear of the
crankshaft, as well as badly worn or broken gear alignment dowels are the result of improper assembly techniques or the reuse of worn or damaged parts
during reassembly. Since a failure of the gear or the gear attaching parts would result in complete engine stoppage, the proper inspection and reassembly of
these parts is very important. The procedures described in the following steps are mandatory." The Service Bulletin was to be complied with during an engine
overhaul, whenever crankshaft gear removal is required or after a propeller strike.
The FAA issued Airworthiness Directive (AD) 2004-10-14 on June 28, 2004. The AD made the Lycoming Service Bulletin mandatory and compliance with the
AD is required before further flight if an engine experiences a propeller strike.
Initially, the pilot reported that he was unaware of any propeller strikes in the past. During a subsequent conversation on December 11, 2014, between the pilot
and an FAA inspector, the pilot reported that a propeller strike had occurred days before the accident flight. The pilot stated that he was unaware of the
corresponding AD and so the AD was never completed after the propeller strike.
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05/04/2015 1145 EDT Regis# N8703W
Acft SN 28-10235
Opr Name: DAVID N PFISTER
Huntington, IN
Apt: Huntington Muni HHG
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
0
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: STN
Events
2. Enroute-cruise - Fuel starvation
Narrative
On May 4, 2015, about 1145 eastern daylight time, a Piper PA-28-235, single-engine airplane, N8703W, was substantially damaged during an off-airport forced
landing at Huntington, Indiana. The pilot and a person on the ground sustained minor injuries. The airplane was registered to, and operated by the pilot. 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. The airplane departed from Anderson Municipal Airport (AID), Anderson, Indiana, and was destined for De Kalb County Airport (GWB), Auburn,
Indiana.
The pilot reported that during cruise flight while about 2,000 feet above ground level (agl) he had a sudden and complete loss of engine power. The pilot
executed a forced landing to a two-lane paved highway and impacted the rear of a pickup truck which was stopped at a traffic signal. The impact resulted
substantial damage to the pickup truck and the complete separation of right wing from the airplane. The main wreckage of the airplane came to rest inverted in
a ditch on the right side of the highway about 250 feet from the initial impact location.
The closest official NWS reporting location was about one mile south from the accident site at Huntington Municipal Airport (HHG), Huntington, Indiana. At 1135
the Automated Surface Observation System at HHG reported wind from 210 degrees at 4 knots, visibility 7 miles in light rain, scattered clouds at 7,500 feet agl,
ceiling overcast at 9,500 feet agl, temperature 15 degrees C, dew point 14 degrees C, and an altimeter setting of 30.13 inches of mercury.
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02/12/2015 1645 EDT Regis# N427AB
Akron, OH
Apt: Akron Fulton Intl AKR
Acft Mk/Mdl PIPER PA 46-350P
Acft SN 4636324
Eng Mk/Mdl LYCOMING TIO-540-AE2A
Acft TT
Fatal
Opr Name: PILOT
Opr dba:
1848
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Summary
The airplane veered off the left side of the runway during landing with a left gusting crosswind. The maximum demonstrated crosswind velocity for the airplane
was 17 knots. The pilot stated that he had applied right rudder and left aileron control inputs for the landing. The airplane left main landing gear touched down
first and when the right main landing gear contacted the runway, a gust of wind lifted the left wing, resulting in a loss of directional control. The airplane veered
off the left side of the runway and into a grass area adjacent to the runway where the nose landing gear collapsed. The airplane sustained substantial damage
to the engine firewall. The pilot and passenger were uninjured. The pilot stated that there was no mechanical malfunction/failure of the airplane.
Cause Narrative
directional control during a crosswind landing in gusting crosswind conditions.
Events
1. Landing - Other weather encounter
2. Environmental issues-Conditions/weather/phenomena-Wind-Crosswind-Contributed to outcome - F
3. Environmental issues-Conditions/weather/phenomena-Wind-Gusts-Contributed to outcome - F
4. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Crosswind correction-Attain/maintain not possible
Narrative
The airplane veered off the left side of the runway during landing with a left gusting crosswind. The maximum demonstrated crosswind velocity for the airplane
was 17 knots. The pilot stated that he had applied right rudder and left aileron control inputs for the landing. The airplane left main landing gear touched down
first and when the right main landing gear contacted the runway, a gust of wind lifted the left wing, resulting in a loss of directional control. The airplane veered
off the left side of the runway and into a grass area adjacent to the runway where the nose landing gear collapsed. The airplane sustained substantial damage
to the engine firewall. The pilot and passenger were uninjured. The pilot stated that there was no mechanical malfunction/failure of the airplane.
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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
Summary
The pilot reported that, during cruise flight, he heard a loud bang and felt a vibration. The cockpit filled with smoke, and oil covered the windshield, both of
which compromised the pilot's view. He opened a side vent window and regained visibility. The pilot chose to land on a nearby landing strip. During the landing
roll, the pilot realized that the strip was short and wet, so he intentionally placed the airplane in a "ground slide." Before the airplane came to a stop, its left wing
struck a fence post, which caused structural damage to the airplane. The pilot reported that, during his postaccident examination of the airplane, he observed a
crack in the engine case near the rear cylinder on the engine's left side. No further examination was accomplished.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: A partial loss of engine power
due to a cracked engine case near the rear cylinder.
Events
1. Enroute-cruise - Loss of engine power (partial)
1. Aircraft-Aircraft power plant-Engine (reciprocating)-Recip eng cyl section-Damaged/degraded - C
2. Environmental issues-Physical environment-Object/animal/substance-Fence/fence post-Contributed to outcome
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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Accident Rpt# WPR13FA072
12/18/2012 1825 MST Regis# N62959
Payson, AZ
Apt: Payson PAN
Acft SN 3107752008
Eng Mk/Mdl LYCOMING TIO-540
Acft TT
Fatal
Opr Name: AMERIFLIGHT
Opr dba:
19188
1
Ser Inj
0
Aircraft Fire: GRD
Events
1. Enroute-cruise - Loss of control in flight
Narrative
HISTORY OF FLIGHT
On December 18, 2012, about 1825 mountain standard time, a Piper PA-31-350, N62959, was lost from Federal Aviation Administration (FAA) radio and radar
contact about 10 miles southwest of Payson, Arizona, during an instrument flight rules (IFR) flight to Phoenix Sky Harbor Airport (PHX), Phoenix, Arizona. The
wreckage was located the following day; the pilot had received fatal injuries and the airplane was substantially damaged. The flight was being operated as
Ameriflight 3853 (AMF3853) as a cargo flight for United Parcel Service (UPS), and was conducted under the provisions of Title 14 Code of Federal Regulations
Part 135. Instrument meteorological conditions prevailed in the vicinity at the time contact with the airplane was lost.
According to information from representatives of the airline and UPS, the flight departed Holbrook Municipal Airport (P14), Holbrook, Arizona, about its
scheduled time of 1700, with a scheduled arrival time of 1730 at Payson Airport (PAN), Payson. According to the driver of the UPS truck who was at PAN and
was scheduled to meet the flight, he never saw or heard the airplane. The driver left PAN about 20 minutes after the flight was due.
According to FAA air traffic control (ATC) information, the flight's first ATC contact was with Albuquerque air route traffic control center (designated ZAB) about
1812, when the airplane was at an altitude of about 13,500 feet; the pilot requested a clearance to PHX. The flight was assigned a discrete transponder code,
radar identified, and cleared direct to PHX, with an altitude crossing restriction that necessitated a descent. Shortly after the airplane reached the assigned
altitude, the pilot requested a lower altitude; his request was denied due to ATC minimum vectoring altitude limitations. Shortly thereafter, radio and radar
contact was lost.
Weather conditions in the area precluded an aerial search until the following day. About 0950 on December 19, 2012, the wreckage was located at the same
approximate latitude/longitude as the last radar target associated with the airplane, at an approximate elevation of 7,000 feet. The accident site was located
about 12.4 miles, on a true bearing of about 213 degrees, from PAN.
According to FAA information, the 28-year-old pilot held a commercial pilot certificate with airplane single- and multi-engine land, and instrument airplane
ratings, as well as a flight instructor certificate with the same ratings. His most recent FAA first-class medical certificate was issued in August 2012.
The pilot was an employee of Ameriflight. According to information provided by the airline, the pilot had a total flight experience of about 1,908 hours, including
about 346 hours in the accident airplane make and model. His most recent flight review was completed in September 2012, in the BE-99 airplane.
According to an airline representative, as of March 4, 2011 (which was prior to the pilot's employment by Ameriflight), the pilot had accumulated 1.4 actual and
84.4 simulated instrument hours. The airline did not track its pilots' actual or simulated instrument time, and the accident pilot's logbooks were not located, so
no determination of his current instrument experience was able to be made.
The pilot was hired by the airline in January 2012, and was initially assigned to the PA-31 airplane. In September 2012, he completed training for, and was
assigned to, the BE-99 twin turboprop airplane.
About a week before the accident, due to the airline's logistical requirements for the holiday season, the pilot was transferred back to the PA-31 airplane. When
he became aware of that transfer, he told his father that he had received "some really bad news," and informed his father of the transfer back to the PA-31. The
pilot told his father that the BE-99 is a "better" airplane, and that he did not "like or trust" the ice protection equipment on the PA-31. The pilot flew the PA-31 a
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total of about 11 hours between his transfer and the accident.
Ameriflight pilots, dispatchers, and managers had very similar opinions about the pilot. In interviews or communications with multiple individuals, they
consistently reported that the pilot was a quiet individual who did well in training, was competent, and did not cause or voice any problems with the airline.
The Gila County Sheriff's Office autopsy report indicated that the cause of death was blunt force trauma. The FAA Civil Aeromedical Institute conducted
forensic toxicology examinations on specimens from the pilot, and reported that no carbon monoxide, cyanide, ethanol, or any screened drugs were detected.
FAA information indicated that the airplane was manufactured in 1976, and was registered to UAS Transervices Inc. of Pasadena, CA. It was equipped with
two Lycoming TIO-540 series engines, and two three-blade Hartzell propellers. The left engine rotated clockwise, and the right engine rotated
counter-clockwise, as viewed from the rear. The tricycle-style landing gear was retractable.
Review of Ameriflight-provided information indicated that the airplane was within its weight and balance limits, and that there was sufficient fuel onboard for the
planned flight legs.
Maintenance records information indicated that the airplane had about 19,200 hours total time in service, and had accumulated about 23,400 flight cycles. The
left engine had accumulated about 1,300 hours since its most recent overhaul, and the right engine had accumulated about 59 hours since its most recent
overhaul.
Review of the maintenance records did not reveal any significant items or trends. The airplane had several unscheduled maintenance items related to the ice
protection systems accomplished in April and May 2012. In September 2012, some de-ice boot patches were replaced, and in October 2012 a pneumatic pump
was replaced. No records of any subsequent discrepancies associated with the ice protection systems were located, nor were any records of any uncorrected
maintenance items located.
According to airline representatives, the airplane was equipped with VOR (very high frequency omni-range) and glide slope equipment for navigation. The
airplane was not equipped with weather radar, or any system to receive and display ground-based weather radar information. The airplane was not equipped
with a GPS receiver, and no evidence to suggest that the pilot had any personal or hand-held GPS units was obtained.
The airplane was equipped with a Century Altimatic IIIC autopilot, which was capable of controlling aircraft in the roll, pitch, heading, and altitude hold modes.
The Ameriflight Standard Operating Procedures (SOP), General Operations Manual (GOM), and the applicable Limitations section of the PA-31 Pilots
Operating Handbook/Airplane Flight Manual (POH/AFM) did not contain any information regarding autopilot usage in turbulence or icing conditions. The
autopilot did not have any automatic disconnect capability, but could be readily deactivated by the pilot. A "CAUTION" in the PA-31 POH/AFM stated "Do not
overpower Autopilot pitch axis for periods longer than 3 seconds because the Autotrim System will operate in a direction to oppose the pilot and will, thereby,
cause an increase in the pitch overpower forces." In addition, Paragraph 3.15 (Rough Air Operation) of Section 3(Emergency Procedures) of the PA-31
POH/AFM stated that "when flying in extreme turbulence or strong vertical currents and using the autopilot, the altitude-hold mode should not be used."
The airplane was approved for flight into light to moderate icing when equipped with wing and empennage deicing boots, electric propeller deicers, electrically
heated windshield, and an ice detection light. Ameriflight representatives and guidance indicated that the airplane was equipped with all four systems.
The airplane was not equipped with the manufacturer-supplied supplemental oxygen system. Ameriflight representatives and guidance indicated that the
airplane was equipped with a portable supplemental oxygen system.
In May 2008, the FAA published a SAFO (Safety Alert for Operators notice) that advised pilots and operators about unexpected in-flight openings of PA-31
nose baggage doors. The SAFO reported that such occurrences "could adversely affect the flight characteristics of the airplane." The SAFO contained a
reference to an FAA supplement delineating FAA-recommended actions regarding the doors and door opening events. That supplement was primarily focused
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on actions to prevent inadvertent door openings.
Although the supplement also stated that the "operator's pilot training program should include emergency procedures training on how to react" and "what to
expect [including]...handling," the FAA did not include any specific information, guidance, or references regarding those aspects. The FAA did not, either during
airplane certification or after issuance of the SAFO, require the airplane manufacturer to develop or provide any such information. The reasons for the
incongruity between the FAA recommendation for such information and training, and the lack of any FAA follow-up to ensure the development and promulgation
of the same, could not be determined.
In November 2008, Piper published mandatory Service Bulletin 1194A, which required certain nose baggage door inspections, and placed life limits on certain
nose baggage door components. Effective July 2009, FAA Airworthiness Directive (AD) 2009-13-06 mandated compliance with Piper Service Bulletin (SB)
1194A. Ameriflight representatives indicated that the airplane was in compliance with the SB and AD.
According to airline representatives, the airline "incorporated the recommendations of SAFO 08013 [in] the summer of 2008." The airline's response included
references to the mechanical and inspection aspects of the supplement. The airline subsequently clarified that it "adopted [SAFO] recommendations 1-4," and
correctly noted that it "could not locate any flight procedures" in the FAA or Piper guidance.
PAN Automated Weather Observations
The 1615 automated weather observation at PAN included winds from 180 degrees at 7 knots, visibility 10 miles, broken cloud layers at 2,800 and 3,000 feet
above ground level (agl), temperature 6 degrees C, dew point 2 degrees C, and an altimeter setting of 29.82 inches of mercury.
The 1635 observation was similar, but with a broken cloud layer at 3,000 feet agl, and an overcast layer at 5,000 feet agl.
The 1655 observation, which was about 5 minutes before the flight's departure from P14, was similar, with broken cloud layers at 2,700 and 3,400 feet agl, and
an overcast layer at 4,400 feet agl.
The 1715 observation, which was about 15 to 20 minutes prior to the flight's estimated arrival at PAN, was similar, with broken cloud layers at 3,100 and 3,500
feet agl, an overcast layer at 4,200 feet agl, and an altimeter setting of 29.80 inches of mercury.
By 1735, which was about the flight's initial estimated arrival time into PAN, the observation included similar conditions, but with scattered clouds at 2,600 feet
agl, and an overcast layer at 3,300 feet agl.
Weather Forecasts
The National Weather Service (NWS) area forecast for the flight and accident region, issued at 1345, called for an overcast ceiling at 7,000 feet, with tops at
FL180, visibilities between 3 and 5 miles, and mist. After 1700 the forecast called for scattered light snow showers, mist, and visibilities around 3 miles.
Sierra, Tango, and Zulu AIRMETs issued between 1345 and 1419, and valid for the flight and accident region for the period of the flight, warned of IFR
conditions with ceilings below 1,000 feet, and visibility below 3 miles in precipitation and mist, mountains obscured by precipitation and clouds, moderate
turbulence below 14,000 feet, and moderate icing between 7,000 feet and FL250. Review of observed meteorological data indicated that all of those conditions
were present at the accident site at the time of the accident.
No SIGMET, Center Weather Service Unit (CWSU) Advisory, or CWSU Meteorological Impact Statements were active for the flight and accident region for the
period of the flight. No PIREPs for severe icing or severe turbulence were received by ATC.
Supercooled liquid water droplets (SLD) is the term for the airborne phenomenon of liquid precipitation at or below freezing temperatures, and SLD can become
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freezing drizzle or freezing rain when it strikes a suitably cold surface, such as the ground or an aircraft. For any official NWS weather products, a weather
forecaster would only issue a weather product that contained the terms "freezing drizzle" or "freezing rain" for the surface forecast; such forecasts are indicative
of SLD aloft.
By design, AIRMETs will include forecasts for moderate icing if applicable, but will not include either the type of icing expected, or any SLD prognoses. Some
National Weather Service products do provide SLD and other icing information, but those products remain "supplemental," meaning that they are not
automatically included in any official aviation weather briefings, and must be specifically sought or requested by the persons or agencies obtaining the briefing.
None of the forecasts or AIRMETs applicable to the flight contained any references to freezing drizzle, freezing rain, or SLD.
Sunset occurred at 1719, and civil twilight ended at 1746 at PAN. The moon was a waxing crescent of 35 percent, and was at its peak elevation at 1724.
Weather Observations and Weather Models
The NWS 1700 Surface Analysis Chart depicted a cold front from southern Nevada southward off the west coast of Mexico, and a stationary front from
southern Nevada eastward into central Colorado. The station models around the accident site depicted air temperatures between about 0 and 8 degrees C, with
temperature-dew point spreads of 10 degrees C or less, a southwest to south wind between 10 and 20 knots, cloudy skies, and light rain and/or light snow.
The NWS 1700 Constant Pressure Charts depicted a mid-level trough just to the west of the accident site, with southwest to west-southwest winds above the
accident site increasing from 30 to 80 knots. The accident site was located in the region of an upper-level jet streak that is typically conducive to precipitation,
and vertical motion in clouds.
Upper air data indicated that the freezing level was located at an altitude of about 7,400 feet. Rime and mixed icing was likely in a cloud layer between 8,000
and 13,000 feet.
Low-level wind shear was indicated from the surface through 9,000 feet, with several layers of possible clear-air turbulence from the surface through 30,000
feet. Infrared data from the Geostationary Operational Environmental 15 (GOES-15) Satellite indicated an abundance of cloud cover over and around the
accident site at the accident time, with approximate cloud-top heights of about 26,000 feet.
Sounding data and data from the Weather Surveillance Radar-1988, Doppler (WSR-88D) indicated that SLD was likely at the flight's altitude at the time of the
accident, and that it was likely that AMF3853 encountered the SLD several minutes before the accident time.
Although several PIREPs of light to moderate icing for central Arizona were issued prior the accident, none reported SLD conditions. The standard format for
PIREPS specifies only the "type and intensity" of icing. In contrast, while SLD can result in icing, it is neither a type nor intensity of icing. SLD is a
meteorological condition that is not necessarily directly detectable by pilots, and would not be included in a PIREP.
There were no lightning strikes near the accident site around the accident time.
A simulation program was run to model the three-dimensional air movements near the accident site at the accident time. The program indicated that mountain
wave activity, as well as updrafts and downdrafts, were likely near the accident site. Up- and downdraft velocities of just over 1,000 feet per minute (fpm) were
likely, and the largest and most rapid transitions from up- to downdrafts occurred near the accident site. According to the model, the last AMF3853 radar target
was located in a downdraft with a velocity between 600 and 1,000 fpm.
Air Traffic Controller Weather Information
According to the information provided by the FAA, the ZAB controllers working the flight had access to the METARs, TAFs, AIRMETs, and PIREPs that were
current for the route of the flight. The Weather and Radar Processor (WARP) was the system that depicted weather information on the controller's radar
display. WARP data was limited to precipitation only, and was sourced from the NEXRAD/WSR-88D system. Precipitation was able to be displayed in either
three or four intensity levels, as a function of the facility. Regardless, the minimum precipitation reflectivity (expressed in "dBZ," a logarithmic scale) required in
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order for precipitation to be depicted was 30 dBZ. Review of the WRS-88D reflectivity data revealed that the values in that area at that time were never higher
than 5 dBZ, and therefore, would not have been depicted on the controller's display.
FAA ATC data archiving permitted the re-creation and playback (referred to as "SATORI") of the aircraft tracks and data tags for the time and location of the
accident airplane's flight, but the system does not capture many of the controller-selectable display variables. The investigation was unable to determine any
details regarding the display settings in use at the time of the accident. Therefore, the SATORI re-creation is not necessarily an exact depiction of what the
controller was presented (scale, colors, etc) during that period.
As noted above, there were AIRMETs valid for the airplane's route of flight. Typically, those are broadcast to aircraft by controllers when received. AIRMET
notification and information is normally provided to controllers by the controllers' supervisor, who receives the information from CWSU personnel or via the
Flight Data Input/Output (FDIO) terminal. If the AIRMET is applicable to a particular aircraft's route of flight, information on how to obtain the AIRMET specifics
is provided when that flight checks onto the frequency. Voice recordings indicate that the controller did not pass any weather related information, including
AIRMETs or PIREPs, to the pilot. The controller's written statement did not indicate what PIREPS or other specific weather information he was aware of at the
time, and the controller was not interviewed by the NTSB subsequent to the accident. Therefore, the investigation did not determine whether the controller was
aware of the AIRMETs, PIREPS, or other weather-related information.
In May 2014, as a result of this and several other accidents, the NTSB issued four Safety Recommendations (A-14-13 to A-14-16) to the FAA, and five to the
NWS (A-14-17 to A-14-21), to improve the communication between the NWS and FAA regarding potentially hazardous weather phenomena such as mountain
waves and turbulence, and to improve the consistency and dissemination of such information to the aviation community.
Accident Pilot's Weather Information
Because the flight was departing from P14, which was not equipped with an Ameriflight dispatch office, the pilot had to obtain his weather and certain other
flight-related information either telephonically from the dispatcher, or from one of the approved internet sources via computer or personal mobile device.
Records indicated that the pilot did not contact flight service or DUAT/DUATS for that information, but such tracking accountability for the other Ameriflight/FAA
approved weather information sources was not available.
Interviews with the dispatchers indicated that the pilot had independently obtained at least some weather information, but the specifics, particularly regarding
the pilot's awareness of the icing AIRMETs, was not able to be determined. The investigation was unable to determine the sources, timing, specific type, or
amount of weather information that the pilot obtained prior to the flight.
The airplane was not equipped with weather radar, or any other weather detection or uplink capability, and the pilot did not have any personal devices with
which he could obtain in-flight weather data. The pilot's only sources of in-flight weather information were the airplane's radios.
COMMUNICATIONS
ATC Communications
The first recorded contact by AMF3853 with any ATC facility occurred at 1811:26, when the pilot contacted ZAB for an IFR clearance to PHX. At 1814:35, after
internally coordinating the handling of the flight, the controller cleared AMF3853 directly to "Phoenix," with an altitude crossing restriction of 10,000 feet 40 miles
"north of Phoenix." The pilot questioned whether the clearance was for him; the controller then repeated the clearance, and the pilot read it back.
No other communications occurred between ATC and AMF3853 until 1823:55, when the pilot requested "lower" due to some "heavy up- and downdrafts." The
controller responded that he was unable to issue lower, that the radar was indicating that the airplane was 500 feet below the assigned altitude of 10,000 feet,
and that the ATC minimum vectoring altitude for that area was 9,700 feet. At 1824:18, the pilot acknowledged that transmission with his flight number and
"roger," which was the final transmission from the airplane.
At 1825:17, the controller advised AMF3853 that radar contact had been lost. The controller attempted to contact the flight directly, without success. He also
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requested other aircraft in the vicinity to attempt to reach AMF3853 by radio, to listen for an emergency locator transmitter (ELT) signal, and to "keep an eye
out for lights...or a fire" on the ground. At 1845:58, the controller asked another aircraft to make a slight track deviation to visually look for a fire. No aircraft
reported any contact with, or indications of, AMF3853. At 1903:23, the controller began communicating on his land line with another controller about the missing
flight, and at 1904, an ALNOT (alert notice) for the missing airplane was issued.
Ameriflight Communications Provisions
According to the Ameriflight General Operations Manual (GOM), the airline's primary means of communicating with its flights was via radio. The GOM stated
that "Ameriflight is able to always be in contact with all of its aircraft" and provided the following ordered list of methods: "Company radio, ARINC [a commercial
vendor], phone patch, Contract service handlers frequencies, [and] ATC." The GOM stated that all Ameriflight aircraft are equipped with a minimum of two VHF
(very high frequency) communications transceivers, and mandated that, exclusive of "arrivals into high density terminal areas," operations in busy terminal
areas, flight crews shall continually monitor an appropriate company frequency at all times during flight operations. The GOM specified that "Company
radio-telephony is to be used for...company business only," including the relay of messages between Ameriflight airplanes. The GOM also stated that flight
crews shall not initiate business related radio communications on company frequency during taxi, flight below 10,000 feet above mean sea level (msl), except
in cruise, and other high cockpit workload periods.
The GOM noted that the airline used two VHF frequencies for company communications, 131.9 MHz (megahertz) inside California, and 122.875 MHz for all
other locations. Outside California, pilots could contact ARINC via the appropriate network frequency, which was depicted on a map stored in each airplane.
AIRPORT INFORMATION
According to FAA information, P14 was not equipped with an operating air traffic control tower (ATCT). The airport elevation was 5,262 feet msl. PAN was
located about 72 miles southwest of P14. Maximum terrain elevation between the two airports was about 8,000 feet msl; that terrain was the Mogollon Plateau.
South of the plateau, the terrain descended rapidly, and the southern edge of the plateau, which was oriented approximately east-west, was known as the
Mogollon Rim. PAN was situated in the basin about 10 miles south of, and 3,000 feet below, the Mogollon Rim.
PAN was equipped with a single paved runway designated 06-24. The runway measured 5,504 by 75 feet, and field elevation was reported as 5,157 feet. PAN
was not equipped with an operating ATCT. There was only one published instrument approach procedure (IAP) for PAN. The IAP was an RNAV (GPS)-A
approach, with category A and B minimum descent altitude minima of 5,720 feet msl, which was 563 feet above airport elevation, and 1 statute mile visibility.
The nearest Victor Airway to PAN was V95. V95 was defined by the 197 degree radial of the Winslow VOR, had a minimum enroute altitude (MEA) of 10,000
feet msl, and passed about 3 miles to the west of PAN.
On-Scene Observations
The coordinates of the accident location were determined to be W 34§ 06' 27.76", N 111§ 28' 14.09", at an elevation of 7,023 feet msl. The accident site was
located on an approximate 40 degree slope, with an approximate downslope direction of 120 degrees magnetic. The terrain was primarily solid or fractured
rock, with numerous loose rocks and small boulders. Much of the wreckage was snow-covered. The pre-accident snow cover appeared to be approximately 1
to 2 feet.
There was evidence of a ground fire, but fire damage was relatively localized. Examination of virgin snow in the wreckage vicinity at about midday December 20
revealed that there was a soot layer present approximately 1-2 inches below the existing top of the snow layer at that time.
The wreckage was highly fragmented. Approximately 90 percent of the observed wreckage was confined to an area approximately 40 feet by 25 feet. The long
axis of that wreckage portion was oriented approximately northeast-southwest, which was cross-slope. Within that area, the main wreckage was tightly
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contained in an area that could be enclosed by an approximate 15 foot diameter circle. Some fragments were strewn irregularly to the southwest, and the
furthest fragment was located approximately 150 feet away from the main wreckage.
A wreckage database and a debris field map were developed. Examination of the debris map, combined with ground scars and vegetation damage, provided
evidence that was consistent with the airplane impacting the ground in a near-vertical trajectory, in a near vertical, nose-down, attitude. The approximate
heading at impact was 225§ magnetic.
Portions of the wing spar, both inboard wings, the main landing gear, both aft engine nacelles, and empennage were identified in the main wreckage area. The
central, fire-damaged portion of the wreckage appeared to be the center wing spar/cabin area. The inboard segments of the left and right flaps were attached to
their respective wing sections, and their positions were consistent with the flaps being retracted at the time of impact.
All three stabilizers remained attached to the aft fuselage. The horizontal stabilizers retained their respective movable control surfaces, and the left horizontal
stabilizer was relatively intact. The right horizontal stabilizer exhibited significant leading edge crush damage in the aft direction. Both horizontal stabilizers bore
evidence of leading edge de-ice boots, but their pre-accident condition and operability could not be determined. The vertical stabilizer exhibited significant crush
damage in the aft and down directions
Fragments of some airplane instruments or avionics were observed in the main wreckage area. Numerous flight- and airplane-related papers, including cargo
manifests, maintenance sheets and operating guidance, were found in the debris field
Recovery Facility Observations
The recovered components were identified when possible, and separated into three main groups of airframe, engine, and propeller. All major components were
identified in the wreckage, and no evidence of any in-flight separation or fire was observed. The nature and extent of the damage precluded any functional
testing of any systems, subsystems, or components
The left wing separated from the fuselage at the root area. The wing was fragmented into multiple sections, and many sections also exhibited crush damage.
Both the flap and aileron were present. The flap drive exhibited no exposed threads, which was consistent with the flaps being retracted at the time of impact.
The aileron was separated from the wing, and the aileron counterweight assembly was separated from the aileron, but was located in the wreckage. Portions of
the main landing gear assembly remained attached to the wing, but damage precluded determination of whether it was retracted or extended at impact. Similar
damage conditions and findings were obtained during the examination of the right wing.
The empennage was fracture-separated from the aft fuselage at the approximate station of the leading edges of the horizontal stabilizers. The left stabilizer and
elevator surface sustained thermal damage, but the outboard section of the elevator was separated, and was not thermally damaged. The right elevator was
fractured into several sections, and only the inboard section remained attached to the stabilizer. Both the left and right elevator caps were recovered. The
elevator stops did not exhibit any peening or bending damage associated with control surface flutter. The elevator nose trim drum shaft exhibited one exposed
thread, which correlated to about 4.5 degrees tab trailing edge up (out of a possible 9 degrees) trim setting.
The vertical stabilizer exhibited significant aft crushing, nearly to its aft spar, along its entire span. The rudder remained attached to the vertical stabilizer. The
rudder trim tab was fracture-separated separated from the rudder, but was still connected by the rudder trim push/pull tube assembly. The rudder trim drum
shaft exhibited seven exposed threads, which correlated to a slight airplane nose right trim setting.
The fuselage and cabin structure, including the wing carry-through spars, was extensively fractured and crushed, and partially fire-damaged. Damage precluded
determination of the presence or open/closed status of the nose baggage door. The forward cockpit structure, furnishings and instrument panel were severely
fractured and crushed. The throttle quadrant was located, but damage precluded the provision of any useful information. The center console, which contained
the fuel selector levers, was not identified in the wreckage.
Several nose landing gear components were identified, but no conclusions regarding gear position at impact were able to be made.
Both fuel selector valves were identified. Examination of the internal passages indicated that one valve was in the "off" position, and that the other valve was in
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the "on" position. One of the two fuel shutoff valves was located; it was in the open (fuel on) position. Damage precluded association of any valves with either
engine.
No components that could be associated with any supplemental or portable oxygen system were identified in the wreckage.
The physical evidence confirmed that the airplane was equipped with pneumatic deicing boots and electric propeller de-icing. Damage precluded determination
of component or system configuration, integrity, or functionality for any of the ice-protection systems.
Engines
Both engines were recovered and examined in detail. Both engines sustained significant impact damage and some fire damage. Impact damage precluded
manual rotation of either engine during the examination. No evidence of any pre-impact deficiencies or failures that would have precluded continued operation
was observed.
Propellers
The recovered wreckage included all six blades, a fragment of one propeller piston, a liberated fragment of one hub, and the aft ends of both propeller hubs,
which remained attached to their respective engines. The damage to both propellers was consistent with severe frontal impact; the propeller hubs were
fragmented, and the blades were separated from their respective hubs. The blades were able to be associated with either the left or right engine due to the fact
that the left and right engines rotated in opposite directions. One or more blades from each propeller assembly exhibited indications of rotational scoring, severe
leading edge damage, twisting, and tearing of blade tips. The blade damage on both propeller assemblies was consistent with engine/propeller rotation under
power at the time of impact. No evidence of any pre-impact deficiencies or failures that would have precluded normal operation was observed.
Pitot Tube
According to Piper and Ameriflight documentation, the airplane was equipped with two heated pitot tubes, mounted on the underside of the airplane nose. The
two switches for the two pitot heat systems were located on the right overhead switch panel.
A portion of one of the two pitot tubes was recovered in the wreckage and retained for detailed laboratory examination, with the ultimate goal of determining
whether pitot heat was being applied at the time of impact. Although the component serial number was visible on the recovered fragment, the item was not
tracked by serial number in the airplane records, and therefore, the investigation was unable to determine which system (left or right) the component was from.
Computed tomography (CT) radiographic scans were conducted at a private laboratory under NTSB supervision to examine and document the internal
configuration of the pitot tube. Review of the images showed that there were a number of high density particles within the body of the pitot tube.
Subsequent to the scans, the probe fragment was sent to the NTSB Materials Laboratory for examination, and mechanical sectioning of the unit to determine
the nature and possible source of the particles. The examination revealed that the separated ends of the sleeve section and the heaters exhibited features
consistent with overstress fracture and gross mechanical deformation. Neither the sheared ends nor the external surfaces of the heaters exhibited signatures of
electrical arcing.
The heater sheaths shared a common ground with the mast housing, and there were no shorts between the heater sheaths and their respective heating
element core wires. Electrical measurements indicated that there were no continuity breaks in the heating element core wires within the recovered pitot tube
fragment. Finally, there were no shorts between the heating element core wires.
The particles in the CT scan were about 1 mm or less in diameter. Most of the particles observed inside the pitot tube were either small balls of braze filler
metal that were stuck to the side of the wall, or small sand fragments. The particles observed in the CT scans were not independently extracted or examined in
detail for composition or other characteristics. Based on the available evidence, NTSB systems engineering personnel determined that the high density
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particles were artifacts of the manufacturing process, and that there was no evidence of any internal arcing event in the probe.
The investigation was unable to determine the pre-accident functionality or operating status of the heater from the recovered pitot tube. The CT scans and the
Materials Laboratory report are available in the NTSB public docket for this accident.
Ameriflight Background Information
Ameriflight was a FAR Part 135 operator, which almost exclusively transported cargo. The airline was headquartered in Burbank, California, but operated in,
and had 12 bases across, the United States. The airline also operated into Canada and Mexico. The cargo fleet consisted of PA-31, BE-99/1900, SA-227, and
EMB-120 airplanes. The airline did not have or utilize any PA-31 or BE-99 FAA-approved motion-based flight training devices. The airline had 12 assistant chief
pilots (one per base), about 250 line pilots, and typically hired between 5 and 15 pilots per month.
The airline had several senior dispatchers. One of them, who was based at Burbank, was also the hazmat program manager. In an NTSB interview, he stated
that he spent about 30 percent of his time in the dispatch function, and the remainder in the hazmat function. The FAA certificate managers, including the
principal operations inspector (POI), were based at the Van Nuys FSDO.
The Phoenix base had about 20 pilots, and primarily operated PA-31 and BE-99 airplanes. Other base personnel included three dispatchers, a station manager,
and an assistant chief pilot.
Ameriflight guidance for flight operations was primarily contained in two airline-produced documents and one Piper-produced document. The two airline
documents were the GOM and the Standard Operating Procedures (SOP) manual. The GOM was company-wide in its applicability. The SOP and the Piper
POH/AFM were specific to the airplane type.
Ameriflight Director of Safety
Although the position was not required by FAR Part 135, Ameriflight had utilized a Director of Safety (DOS) for several years prior to the accident. The DOS
was stationed at the airline's base in Oakland, California. He was also a "Division Manager" responsible for operations, sales, and maintenance services in
central California and Nevada. The DOS stated that he spent about "5 to 10 percent" of his time on DOS duties, and had no safety subordinates or assistants,
but could obtain support when necessary. The DOS stated that at the time of the accident, his position was still being defined. He had two basic safety tasks,
which were analyzing safety issues as they arose, and developing an incident database. The DOS stated that neither his department nor the airline had a
dedicated safety budget.
His primary safety concerns included pilot experience levels in terms of time and variety, especially with IFR operations and weather, pilot decision making
ability and judgment, and training-related issues. He noted that the company had observed that the Phoenix based pilots tended to have more difficulties and
perform less well in IFR than Portland (Oregon) based pilots, and that this was likely a result of the typically more benign weather in Phoenix.
Although the airline did have a telephonic "safety hotline" that was open to all employees, including pilots, as of the date of the accident, the hotline had
received few inputs. The airline also had a non-punitive written event and hazard reporting system referred to as its "immunity-based Safety Reporting System."
Employees, including pilots, could also email or telephone the DOS directly, or visit the Safety Department office in person. The scope of these reports was not
limited to flight operations only; it included all safety-related aspects of all company operations. Employee reporting of events or hazards was not mandatory.
The reporting system did not automatically compile, categorize, or assign risk levels to the reports. All events and reports were reviewed by the DOS or other
company safety personnel, and dispositioned accordingly. When significant procedural changes were implemented, employees were advised of such changes
via internal Alert Bulletins, and those changes were eventually incorporated into the GOM.
As of the date of the accident, the DOS was developing a "safety incident database," which was being physically populated by the DOS, based on his review of
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inputs from the Safety Reporting System. The DOS stated that his planned risk mitigation strategies included increased standardization of flight procedures
across airplane types and bases, modifying training to account for root causes for mistakes, and developing and implementing more proactive risk management
strategies.
Ameriflight Dispatch Information
FAR Part 135 did not require Ameriflight to maintain or use FAA-defined dispatch personnel or procedures. According to Ameriflight representatives, the airline
employed dedicated personnel in a dispatch-like capacity, but some of those personnel did not hold FAA dispatcher certificates. The Ameriflight GOM stated
that the airline "shall provide enough Ameriflight qualified dispatchers...to ensure proper operational control of each flight, and cited the FAA definition of
operational control, which was the exercise of authority over initiating, conducting, and terminating a flight. Ameriflight dispatchers report to their assigned
Assistant Chief Pilot (ACP).
Normal Ameriflight dispatch procedures included creating flight releases for the pilots. The releases contained weather, aircraft, maintenance, flight time, duty
time, cargo, and fuel information. All weather products in the flight release were provided by a commercial vendor, WSI. The GOM stated that prior to "each
flight, the Captain and Dispatch must review...meteorological information that could affect the safety of flight," and that dispatchers "will advise flight crews of
actual weather, which could affect the safety of the flight enroute."
According to the GOM, there were six internet-accessed weather data sources that the FAA approved the airline to utilize. These were DUAT/DUATS,
Jeppesen, WSI, Meteorlogix, Fltplan.com, and Aviation Digital Data Service (ADDS). The GOM also noted that "each Dispatcher is to complete thorough
pre-flight planning for each flight under his control," including variables such as weather, NOTAMs, facility irregularities, and other temporary conditions.
Pilots departing from an airport where there was an Ameriflight dispatch office physically reported to the office to speak with the dispatchers, access and review
flight- and weather-related information, and obtain their releases. As was the case for AMF3853, pilots whose flights originated at remote airports spoke to the
dispatcher and obtained their release information via telephone. At such airports, pilot access to flight- and weather-related information was a function of the
facilities and equipment (primarily a computer terminal with internet access) available at the airport, as well as whether other pilots were using or waiting for the
same access. Ameriflight representatives reported that pilots could use their personal mobile devices as an alternate means of accessing that information.
They also stated that the pilot was not provided with a company-issued mobile telephone, computer, or tablet.
According to at least two Ameriflight representatives, pilots were required to notify dispatch once they were airborne, in order to communicate their departure
and estimated arrival times. In contrast, the GOM implied, but did not mandate, that pilots were to contact dispatch to communicate their departure times after
they were airborne. The SOP did not contain any guidance regarding this procedure, nor would it be expected to. Discussions and communications with other
Ameriflight personnel indicated that dispatchers also relied on pilots' estimated departure times, and/or telephone notifications by UPS drivers who transferred
cargo to or from the flights.
Pilots were responsible to notify dispatch if they were unable to complete their planned flight legs, and those notifications could be accomplished via radio while
airborne. According to the Operations Manager, if there was any pre-flight doubt about the potential to complete the flight, the pilots and dispatchers would
agree on possible diversion plans, as well as communication plans. The typical diversion contingency plan was for the flight to continue on to its hub/base
airport. In the case of AMF3853, although no such pre-flight discussion occurred between the pilot and dispatcher, the default plan if the flight could not land at
PAN was for the flight to continue on to PHX, the hub/base airport.
Ameriflight dispatchers used a computer software suite that they referred to as "FlightOps," which included weather depiction capability, to conduct a significant
portion of their tasks, including flight monitoring and tracking, and weather overlays. The GOM stated that "FlightOps is Ameriflight's proprietary data collection
and management system for all flight operations." As one subset of its capabilities, the system provided three levels of alerts to dispatchers when a flight was
overdue. The system alert function was not de-selectable by any personnel.
According to one of the Burbank-based senior dispatchers, the automated FlightOps system alert levels were a function of the how late (5, 10, and 15 minutes)
the flight was beyond the arrival time that was input by the dispatch personnel. The senior dispatcher stated that the 15 minute alert provided both visual and
aural notifications to the dispatchers. The GOM also stated that the system had three alert levels, but specified the overdue times as 15, 30, and 45 minutes
after the estimated arrival time.
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Ameriflight Dispatch Activity Summary
On the evening of the accident, there were two persons working in the Phoenix dispatch office, which was the office responsible for AMF3853. One was a
dispatcher, and the other was a dispatcher/operations manager. NTSB interviews with those two personnel revealed that they did not have any flight-safety
concerns regarding the weather, and that they expected the pilot to be able to land at PAN.
According to the dispatcher, per company procedure, the pilot first telephoned about 1600 to "check in." At that time, the pilot was at P14, and he told the
dispatcher that he would call back for his "full release" once he had the values for the weight of his cargo. After that conversation, the dispatcher checked the
PAN weather, and observed that there was a broken cloud layer at 3,000 feet agl, and an overcast layer at 5,000 feet agl.
About 1650, the pilot telephoned the dispatcher, and provided his cargo weight and some other information, including the fact that the weather at both P14 and
PAN "was VFR." The pilot and dispatcher did not discuss the weather in detail, and did not discuss how the pilot planned to descend into PAN, given the cloud
cover and the lack of navigation equipment required to conduct an instrument approach into PAN. The dispatcher provided the flight release for the flight to
PAN, and then on to PHX.
According to Ameriflight representatives, the pilot did not notify dispatch that he had departed P14. The dispatchers based his departure time on the pilot's
estimated departure time, and then confirmed that in a telephone call with the UPS driver who provided the cargo at P14, and reportedly observed the airplane
depart.
At some point between the two telephone calls from the pilot to the dispatcher, the UPS driver who was scheduled to meet the airplane in PAN called the
airline. The driver inquired of the airline's Operations Manager whether the pilot was expected to land at PAN, because the weather was deteriorating there. The
manager told the driver that he did not yet know, because there was no terminal area weather forecast available for PAN. The manager told the driver that he
would call the driver as soon as the airline knew that the flight would not be able to land at PAN.
About 1740, the UPS driver again called the airline to inquire about the status of the flight, since it was about 10 minutes overdue at PAN. The Operations
Manager was aware that the airplane departed P14 about 1700, but he told the UPS driver that he did not have any more-recent information. Subsequent to
that call, the dispatch department attempted to contact the pilot directly via radio and the pilot's personal mobile telephone, without success. They also
attempted to reach the pilot indirectly via radio through other company flights.
About 1805, just as the Operations Manager was initiating the company's lost aircraft procedure, the dispatch department received word that the pilot of another
company flight, AMF2863, was in touch with the subject flight, AMF3853. The dispatchers asked AMF2863 to instruct AMF3853 to forego landing at PAN and
proceed to PHX. AMF2863 relayed the request, and received an acknowledgement from AMF3853. No further communications between AMF3853 and either
dispatch or any other Ameriflight flights occurred. About 1835, the dispatchers received a telephone call from PHX terminal radar approach control (TRACON)
that contact with AMF3853 had been lost.
Neither individual in the PHX dispatch office reported that he received any automated FlightOps alerts regarding the flight, either for when it was due at PAN, or
at PHX. A subsequent re-check with Ameriflight personnel indicated that they did not receive any alerts. Due to the facts that predicted arrival time was
manually input by the dispatchers, and neither those times nor the times of any of the flight-related telephone calls were known with certainty, it was possible
that either the requirements to trigger the system alerts had not been met, or that the dispatchers were already working to locate the flight when the alerts were
issued. The investigation was unable to determine whether those alerts were generated, or if not, why not.
Ameriflight IFR vs VFR Operations
The GOM stated that the airline's flight operations will be conducted utilizing either FAA visual flight rules (VFR) or IFR flight plans, or in accordance with
approved Ameriflight company flight locating procedures. According to the Operations Manager, if there was doubt that a flight could be completed under VFR,
the airline prefers that the flight be conducted IFR. Due to the potential for delays and circuitous routes associated with IFR flights, in the interests of
expediency, many Ameriflight flights are conducted VFR, particularly in the Phoenix area.
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The GOM stated that night operations were to be conducted under IFR, except that "in the few locations where IFR operation is impracticable, company
approved VFR night routes are available." At IFR flight plan could be closed within 10 miles of the destination airport, and the flight continued VFR, if the
destination weather was reported to be 10 miles or greater visibility with a ceiling was 4,000 feet or higher, the destination airport was in sight by the pilot, and
would remain so through the landing.
The GOM stated that the approval of any VFR night route was to be accomplished by the Chief Pilot or the Director of Operations, that each VFR night route
would be published at each base for review, and that a copy would be maintained by the Chief Pilot. It also stated that "verbal VFR night routes are not
approved." The airline did not maintain historical records of their VFR night routes, and therefore the investigation was unable to determine whether the P14 PAN route was an approved VFR night route on the date of the accident.
Neither the GOM nor the SOP defined "night." The FAA defined night as "the time between the end of evening civil twilight and the beginning of morning civil
twilight, as published in the Air Almanac." The FAA, GOM, and SOP did not define evening civil twilight, and the Air Almanac was no longer in publication. The
United States Naval Observatory (USNO) defined evening civil twilight as ending "when the center of the Sun is geometrically 6 degrees below the horizon."
According to a representative, the airline uses the FAA definition of "night."
Based on the flight's expected arrival time of about 1730 into PAN, and the USNO civil twilight end time of 1746, the P14-PAN leg of the flight would not qualify
as a night flight.
According to the GOM, "Ameriflight used IFR flight plans stored in FAA Air Route Traffic Control Center computers...[which]...automatically become available at
the departure point about 30 minutes prior to scheduled departure time and will be held for about 1.5 hours past departure time." The GOM noted that flight
crews could extend the time window by contacting the appropriate ATC facility.
Ameriflight Unusual Attitude Training
The FAA Principal Operations Inspector (POI) assigned to Ameriflight reported that the airline conducted its PA-31 unusual attitude training in actual aircraft,
instead of ground-based simulators or procedures training devices, due to the limitations of the ground-based equipment. However, he stated that the airborne
training was conducted "correctly" and "well." He noted that the airline conducts full stalls in aircraft types for which it does not have simulators. The Ameriflight
PA-31 SOP contained explicit guidance regarding unusual attitude recovery completion standards. According to airline records, the pilot successfully completed
the Ameriflight unusual attitude training.
Supplemental Oxygen Information
Paragraph 91.211 ("Supplemental Oxygen") of the Federal Aviation Regulations required that the pilot be provided with and use supplemental oxygen for that
part of the flight that was of more than 30 minutes duration at cabin pressure altitudes above 12,500 feet msl and up to and including 14,000 feet msl, in order
to preclude hypoxia.
According to FAA publication FAA-H-8083-25, Pilot's Handbook of Aeronautical Knowledge, the brain is "particularly vulnerable to oxygen deprivation. Any
reduction in mental function while flying can result in life threatening errors." The document further stated that "All pilots are susceptible to the effects of oxygen
starvation, regardless of physical endurance or acclimatization. When flying at high altitudes, it is paramount that oxygen be used to avoid the effects of
hypoxia" and as "altitude increases above 10,000 feet, the symptoms of hypoxia increase in severity."
The GOM stated that all Ameriflight airplanes carried enough supplemental oxygen to satisfy the applicable FAA regulations, and that flight crews were
responsible for ensuring the quantities were sufficient prior to each departure. The GOM specified that PA-31 pilots were to utilize supplemental oxygen for any
portion of a flight greater than 30 minutes above 10,000 feet through 12,000 feet, and continuously whenever the airplane was operating above 12,000 feet.
PA- 31 Ice Protection Systems and Procedures
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Wing and empennage deicing was accomplished via pneumatic boots on the leading edges of the wings and all three stabilizers. System operation was
controlled by a pilot-activated, momentary-on switch located in the overhead switch panel. Each manual actuation of the switch activates all the boots a single
time. Propeller deicing is accomplished via a series of electrical resistance heating pads on the propeller blades. Activation of the propeller deicing system
results in automatic, cyclic heating of all blades until the system is selected off by the pilot. The electrically heated windshield was controlled by a switch on the
overhead switch panel.
The Section 9 Supplement of the Piper POH/AFM provided the following guidance regarding the use of the wing and empennage deicing boots: "Most effective
surface deicing is obtained if a thickness of 1/4 to 1/2 inch of ice is allowed to accumulate before the deicers are activated."
The Ameriflight GOM stated that flight crews were to activate pitot heat any time the aircraft was flying in visible moisture, regardless of the temperature.
However, the Ameriflight pitot heat procedures differed between the PA-31 and the BE-99; PA-31 procedures were per the GOM, while in contrast, BE-99
normal procedures called for activation of pitot heat after engine start, and use for the entire flight.
The GOM stated that in order to "preclude the formation of structural ice, flight crews shall activate all de-ice/anti-ice systems, except leading edge de-icing
boots, prior to temperatures reaching" 5 degrees C during flight in visible moisture. Finally, the GOM noted that the pneumatic leading edge de-icing boots were
to be activated "upon the first indication that the adhering ice has reached the point where it can be removed by the expansion of the boots."
The Ameriflight PA-31 SOP stated that "it is important that the flight crew be able to properly recognize what kind of ice is likely to form and what kind of ice is
accumulating on the aircraft. There is a significant amount of contradictory information regarding in-flight anti/de-icing techniques published by various sources.
At Ameriflight, we DO NOT [capitals original] begin exercising pneumatic boots at the first sign of ice accumulation....Company guidelines direct the flight crew
to use pneumatic boots when ice accumulation is between ¬ - « inch on the boot surface." The SOP then stated that "'due to dynamic situations the guidelines
are variable and will change from situation to situation," and that "the captain must make the overall determination as to when the pneumatic boots will be
used." The SOP did not provide any elaborating guidance regarding the variability of the guidelines, or any specifics regarding "situation" changes.
Industry Guidance Regarding De-Icing Boots
For over 60 years, pilots have been taught to wait for a prescribed accumulation of ice before activating the deicing boots, in order to prevent "ice bridging." Ice
bridging is a perceived phenomenon associated with the premature activation of deicing boots while operating in icing conditions. The theory holds that with
thin, "plastic" accumulations of ice, boot activation re-shapes the ice profile around the expanded boot, which remains after boot deflation, thus rendering the
boot ineffective at removing ice.
In the 1990s, as a result of several icing-related accidents, the FAA led an industry review of icing phenomena, and in-flight de-icing practices and
effectiveness. In 2007 the FAA issued Advisory Circular (AC) 91-74A, followed by a 2008 NTSB Safety Alert (SA). The AC discussed a broad spectrum of icing
information and procedures, while the SA focused on the use of deicing boots. These two documents included the following information and guidance:
- As little as 1/4 inch of leading-edge ice can increase stall speed 25 to 40 knots
- There are no known cases where ice bridging has caused an incident or accident
- Ice bridging is extremely rare, if it exists at all
- Autopilot usage can mask changes in the handling qualities of the airplane; such changes could be precursors to premature stall or loss of control
- Deicing boots should be activated as soon as icing is encountered, unless the manufacturer's guidance specifically directs otherwise
- Limit the use of, or deactivate, the autopilot in icing conditions
Industry Guidance on Freezing Rain and Freezing Drizzle
Freezing drizzle and freezing rain were conditions that were not included in the FAA certification requirements for all aircraft, including the accident airplane
make and model. This means that even when an aircraft is approved for flight into known icing, that approval does not include freezing rain or freezing drizzle,
or conditions with a mixture of supercooled droplets and snow or ice particles.
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In 2000, the New Zealand Civil Aviation Authority (NZ CAA) published its "Aircraft Icing Handbook." In part, the document stated that "Pilots should rely on
visual and tactile cues to determine the presence of SLD. After confirming SLD, they must divert immediately." It then stated that pilots should "Disengage the
autopilot and hand-fly the aeroplane. The autopilot may mask important handling cues, or may self-disconnect and present unusual attitudes or control
conditions."
The NZ CAA Handbook also stated that "Flight crews must be especially wary of automation during icing encounters. Autopilots ... can mask the effects of
airframe icing and even contribute to ultimate loss of control." It continued by noting that autopilots can and have disconnected due to icing conditions, and that
the "autopilots are not malfunctioning; they are conforming to design parameters. When they were approved, the rules assumed they were non-mandatory
equipment. The assumption was that the crew would remain continuously aware of what the autopilot was doing and how it is flying the aeroplane. That, of
course, is not always a valid assumption." The Handbook also stated that "When workload allows, crews should manually fly their aeroplane in icing conditions
so they can monitor control forces and feel trim changes."
The 2007 FAA Advisory Circular (AC) 91-74A "Pilot Guide: Flight in Icing Conditions" presented a discussion of meteorological circumstances and visual cues
to help pilots recognize the possible existence of SLD conditions. The AC advised that "care should be exercised when using an autopilot in icing conditions....
When the autopilot is engaged, it can mask changes in handling characteristics due to aerodynamic effects of icing that would be detected by the pilot if the
airplane were being hand flown." It also stated that if the autopilot disconnects abruptly, "the pilot is suddenly confronted by an unexpected control deflection."
Finally, the AC stated that pilots "may consider periodically disengaging the autopilot and hand flying the airplane when operating in icing conditions. If this is
not desirable because of cockpit workload levels, pilots should monitor the autopilot closely for abnormal trim, trim rate, or airplane attitude. As ice accretes on
aircraft without autothrottles, the autopilot will attempt to hold altitude without regard for airspeed, leading to a potential stall situation."
In 2010, in response to an accident that was the result of an encounter with freezing rain/drizzle, the FAA issued Safety Alert for Operators (SAFO) 100006,
entitled "In-Flight Icing Operations and Training Recommendations." The stated purpose was to provide "information concerning approved training programs for
flight crewmembers and inadvertent encounters of in-flight icing conditions, including freezing drizzle/freezing rain." The SAFO stated that "Freezing drizzle and
freezing rain aloft are considered synonymous with supercooled large droplets (SLD), i.e. those icing conditions containing droplets larger than those required to
be demonstrated in aircraft icing certification criteria. SLD may result in ice formation beyond the capabilities of the airplane's ice protection system to provide
adequate ice protection."
Ameriflight Procedures Regarding Freezing Drizzle and Freezing Rain
According to an Ameriflight representative, the airline provided a discussion of supercooled large droplets in initial training, and "guidance for the icing issues
that will develop from these droplets is also trained and discussed" in the airline's manuals.
The GOM prohibited departures "during" either freezing drizzle qualified as moderate or heavy, or freezing rain qualified as moderate or heavy. The GOM
prohibited flight into severe icing, which was congruent with the FAA-approved POH. The GOM defined severe icing as a situation "where the rate of
accumulation is such that de-icing/anti-icing equipment fails to reduce or control the hazard," and stated that "immediate diversion is necessary."
The deicing fluid holdover time tables noted that "no holdover time guidelines exist" for freezing drizzle, or light, moderate, or heavy freezing rain. Neither the
POH nor the GOM explicitly stated that, once airborne, flight into moderate or heavy freezing drizzle or freezing rain was prohibited, although it could possibly
be inferred or extrapolated from the departure guidance.
ATC Ground Tracking Radar Information
Two sets of ATC ground tracking radar information associated with AMF3853 were provided to the NTSB investigation. The first set consisted of an annotated
image of radar flight tracks, and extended from 1704 to 1824. This set contained only coarse-interval time and altitude annotations; no corresponding electronic
file of the radar target data was provided by the FAA. The second set was an electronic file of radar target data, with a sample rate of 12 samples per second.
That dataset extended from 1811 to 1824, which partially overlapped the time period of the first segment.
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ATC Radar Flight Track Annotated Image
The annotated image of radar flight tracks was developed by FAA personnel from the Denver Air Route Traffic Control Center (ZDV), using data from ZAB. The
image depicted radar tracks for two different aircraft. One track was associated with AMF3853, and the other was for a Beech King Air, N918VS.
The AMF3853 track was annotated with 10 text boxes that presented time, location, altitude, and transponder code information. Review of the AMF3853 track
information revealed that it consisted of two distinct segments. The first segment captured the period from 1714 to 1731, and the second segment captured the
period from 1755 to 1824. The investigation was unable to determine the location and altitude of airplane between 1731 and 1755.
The first segment was derived from 1200 transponder code target data which FAA personnel determined to be from AMF3853, after its departure from P14, but
before it was assigned the discrete transponder code 2651 for the IFR portion of its flight. The second segment began with 1200-code portion of the flight, but
also included the full discrete-code portion of the flight.
The first annotated target in the first segment of the track was at 1703:52, and was located about 8 miles southwest of P14. No altitude data was provided for
that target. The track progressed southwest directly towards PAN, but then made a 180 degree left turn about 15 miles northeast of PAN, and terminated about
25 miles northeast of PAN. The last radar target in that segment of the track had a time tag of 1731:10. The track data indicated that the airplane reached a
maximum altitude of 13,500 feet just after the course reversal turn, and then descended to 12,600 feet by the end of that track segment.
The first radar target in the second track segment was situated about 7 miles northwest of the last target in the first segment, 25 miles northeast of PAN, at an
altitude of 10,600 feet. That target had a time tag of 1755:09, which was 24 minutes after the last target of the first segment. According to FAA personnel, there
were no radar targets in that area during that time period that could be associated with AMF3853. They also noted that due to the radar antenna location and
the intervening topography, the most likely explanation for the gap in target data for AMF3853 was that the airplane was below the radar coverage floor during
that interval. After the gap, the track proceeded northwest (which was not towards PAN) about 20 miles, before turning south, and then southwest. The
maximum altitude annotated on that segment of the track was 13,800 feet. The latter portion of that second track segment bore the discrete 2651 transponder
code that was assigned to AMF3853, and was congruent with the second, electronic dataset.
ATC Radar Data Dataset and Derived Airplane Performance
The target data for this dataset was provided by the Phoenix air route surveillance radar (ZPHX ARSR-1E) facility, which was located approximately 18 miles
south of the impact location. NTSB engineering personnel conducted a brief radar study to derive selected airplane performance values, in order to assist the
investigation.
The first secondary radar target associated with the airplane was recorded at 1811:57, which indicated the airplane was at an altitude of 13,600 feet. The last
secondary target was recorded at 1824:21, and indicated an altitude of 9,900 feet. The impact site was situated about one half mile beyond the last target
location, along a line extrapolated from the recorded ground track, at an elevation of 7,023 feet.
The airplane's ground speed and rate of climb were calculated from the radar data. The raw-calculated groundspeed values displayed significant variations that
were not consistent with the airplane's performance capabilities. Some of those variations were artifacts of the data uncertainties of the radar system, and
data-smoothing techniques were applied to provide more realistic values. The smoothed data revealed that the airplane began a descent about 1815, and
leveled off near 10,000 feet about 1820. The descent to 10,000 feet was conducted at a rate of about 900 fpm. From 1817 to 1820, the ground speed was
approximately 160 knots. As the airplane leveled off, the speed decreased, and at the time of the last radar target, the ground speed was calculated to be 120
knots. The altitude trace from 1820 on was relatively constant, except for a rapid 400 foot loss, and a slower increase, during the last 36 seconds.
According to the manufacturer's POH, the clean-wing stall speed was approximately 75 knots. The normal airspeed operating range (green arc) was 77 to 185
knots, the smooth air caution range (yellow arc) was 185 to 236 knots, and the never exceed speed (red line) was 236 knots. The minimum control speed was
76 knots.
Comparison of the airplane's published performance capabilities and limitations with the radar-derived performance did not reveal any exceedances or
discrepancies between the two.
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ATC Radar Data Altitude Summary
Review of the radar data indicated that the airplane was above 10,000 feet for at least two different periods. The first period began no later than 1714 and
ended no sooner than 1731. The second period began no later than 1755 and ended at 1819. Based on these data, the total time above 10,000 feet, although
possibly discontinuous, was at least 41 minutes.
Review of the ATC radar data indicated that the airplane was above 12,000 feet for at least two different periods. The first period began no later than 1725 and
ended no sooner than 1731. The second period began no later than 1805 and ended at 1816. Based on these data, the total time above 12,000 feet, although
discontinuous, was at least 18 minutes.
Beech King Air N918VS Information
The FAA-provided annotated radar track image also presented a partial track of another, similar airplane, Beech King Air N918VS. That track indicated that
N918VS was operating in approximately the same location, about the same time, as AMF3853, but was 2,000 feet higher. In addition, at the time of the
accident, N918VS was on the same ATC frequency, and communicating with the same controller, as AMF3853. N918VS was using the radio call sign
"lifeguard" in its communications with ATC. Immediately after the controller lost radar and radio contact with AMF3853, he solicited N981VS for assistance in
contacting AMF3853, and also listening for an emergency locator transmitter (ELT) signal or visually detecting the other airplane. N981VS rendered the
requested assistance, but was unsuccessful in all three aspects. N918VS reported that it was "in and out of the [cloud] tops," which impeded its crew's ability
to visually detect the other airplane or the ground.
The N918VS radar track began about 1800:00, and the last annotated radar target on that track was for time 1826:57. Comparison of the AMF3853 and
N918VS radar tracks indicated that N918VS was about 6 minutes behind the accident airplane. The N918VS radar track traversed southwest, parallel to, and
offset about 3 miles southeast of, the final section of the AMF3853 track. The N918VS radar track depicted that the airplane remained level at 12,200 feet msl,
and flew almost directly over the last tracked location of AMF3853.
In an interview with an FAA inspector, the pilot of N981VS reported that he encountered "almost continuous moderate turbulence" and trace amounts of ice
during that flight segment. Review of the communications between N918VS and the ATC controllers revealed that N918VS did not report any weather-related
abnormalities or difficulties during its transit of the accident locale, and did not request any altitude or route changes due to the weather conditions.
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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
Summary
The pilot reported that, during the preflight inspection, he checked both the left and right brake reservoirs for proper servicing, and he found that they were
ready for flight. During the landing roll, the pilot applied the left and right brake pedals; however, the left brake did not respond, and the airplane departed the
right side of the runway.
Postaccident examination of the airplane revealed that there was a hydraulic fluid leak in the left main landing gear brake line. Further examination revealed
that the brake line failed due to a fatigue crack that had propagated through the cross-section of the brake line, which resulted in the hydraulic fluid leak. The
fatigue cracking was likely due to the detachment of the swaged compression sleeve and nut from the brake line due to exfoliation corrosion. The exfoliation
corrosion likely resulted from or was exacerbated by consistent introduction of water and contact between two the different metals in the aluminum sleeve and
the stainless steel brake line.
A review of the airplane's maintenance records revealed that the airplane's last annual inspection occurred about 3 months before the accident. According to
the mechanic who performed the inspection, he performed a visual inspection of the brake system for looseness, leakage, and corrosion and physically
checked the tightness of the "B" nut at the brake caliper in accordance with the 100-hour phase checklist; however, he did not note any problems with the left
brake line.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The failure of the left main
landing gear brake line during landing due to the loss of hydraulic fluid. Contributing to the accident was a fatigue crack through the brake line that had formed
due to contact with a swaged sleeve as a result of exfoliation corrosion.
Events
1. Prior to flight - Aircraft inspection event
2. Prior to flight - Preflight or dispatch event
3. Landing-landing roll - Sys/Comp malf/fail (non-power)
1. Aircraft-Aircraft systems-Landing gear system-Landing gear brakes system-Failure - C
2. Aircraft-Aircraft systems-Landing gear system-Landing gear brakes system-Fatigue/wear/corrosion - C
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
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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."
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
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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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09/08/2013 1656 CDT Regis# N8362C
Guntersville, AL
Apt: Guntersville Municipal 8A1
Acft Mk/Mdl PIPER PA-32R-300
Acft SN 32R-7680099
Eng Mk/Mdl LYCOMING TI0-540-K1A5D
Acft TT
Fatal
Opr Name: BONDS THOMAS P
Opr dba:
5156
0
Ser Inj
0
Aircraft Fire: NONE
Events
2. Enroute-cruise - Loss of engine power (total)
Narrative
On September 8, 2013, about 1656 central daylight time, a Piper PA-32R-300, N8362C, registered to and operated by a private individual, was substantially
damaged during a forced landing in a lake short of a runway at Guntersville Municipal Airport-Joe Starnes Field (8A1), Guntersville, Alabama. Visual
meteorological conditions prevailed at the time and no flight plan was filed for the 14 Code of Federal Regulations (CFR) Part 91 personal, local flight from
Northeast Alabama Regional Airport (GAD), Gadsden, Alabama. The airplane sustained substantial damage and the private pilot and 1 passenger sustained
minor injuries. The flight originated about 1609 from GAD.
The pilot stated that before departure he performed a preflight inspection of the airplane which included checking the fuel tanks and low point of the fuel system
for contaminants; none were found. The flight departed with about 20 gallons fuel in each wing fuel tank and the fuel selector positioned to the left tank. After
departure he flew over the passenger's house then flew North to Guntersville, then flew over the lake. Because of haze, he decided to return to GAD. About 40
to 45 minutes into the flight, he switched the fuel selector to the right tank. The flight continued and about 15 minutes after switching tanks, the engine quit
suddenly; there was no sputtering and the propeller continued to rotate. Immediately before the loss of power the airplane was flying at 3,800 feet, and the
engine was set to 2,250 to 2,300 rpm, the manifold pressure was between 22 and 23 inches, and the mixture was leaned 75 degrees rich of peak, consuming
approximately 15 gallons-per-hour. He glanced at the fuel pressure and it was still in the normal range. At that point he was flying in a southerly direction and
was 3 to 4 miles northeast of 8A1. He turned to the right to fly to 8A1, and immediately switched tanks, and turned on the auxiliary fuel pump, but engine power
was not restored. He pitched to maintain 120 miles-per-hour (mph) and continued towards 8A1. He switched tanks 3 to 4 times in an effort to restore engine
power but with no effect.
When near 8A1, he called in on the common traffic advisory frequency and advised he would be attempting an emergency landing. The winds favored runway
21, and while on approach to that runway with the flaps retracted, the airplane was slowed to the point that the auto extend system caused the landing gear to
extend. He estimated the flight was about « to _ mile from the approach end of runway 21 at that time. Unable to reach the runway, he landed the airplane in
the water about 100 yards from land. The airspeed at touchdown was 70 mph, and the airplane did not go inverted at touchdown. The airplane came to rest in 3
to 4 feet of water north of the airport; the left wing spars were fractured and the wing remained connected by flight control cables. He further stated that if the
landing gear had not extended automatically when it did, which he was not planning for, he felt he could have landed on land.
Following recovery of the airplane, inspection of the airplane and engine was performed by a Federal Aviation Administration (FAA) airworthiness inspector.
Following removal of the engine cowling, the single drive dual magneto was found separated from the engine accessory case, but remained attached by the
ignition harness. The lower magneto securing hardware was not attached to the stud and was not located; the threads of the stud were not damaged.
Inspection of the upper magneto securing stud revealed a portion of the magneto flange remained secured under the clamp, which remained secured to the
stud by a flat washer, internal lock washer, and nut. The upper stud securing hardware was retained, and the magneto was removed from the engine
compartment, air dried, and found to operate normally during operational testing. Cursory inspection of the magneto revealed a portion of flange was fractured.
Further inspection of the engine revealed crankshaft, camshaft, and valve train continuity was confirmed, along with compression and suction in each cylinder
during hand rotation of the crankshaft. Inspection of the fuel system components of the engine revealed the servo fuel injector and manifold valve contained
fuel. No other engine abnormalities were noted. The magneto and upper securing hardware were retained and sent to the NTSB Materials Laboratory located in
Washington, D.C.
Inspection of the airframe by the FAA inspector revealed fuel was present in both fuel cells. Continuity of the fuel system was demonstrated by application of
compressed air through the fuel lines at each wing attach; no obstructions were noted and normal function was noted on both sides. An oil sheen was noted on
the exterior bottom fuselage skin. The on-board GPS receiver was retained and sent to the NTSB Vehicle Recorder Division located in Washington, D.C.
According to the NTSB Vehicle Recorder Division GPS Factual Report, power was applied to the unit and it started normally. Data was downloaded from the
unit without difficulty using Garmin supplied software; the first data point was at 1601:35, while the last data point was at 1655:47. Plotting of the data revealed
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that after takeoff, the flight proceeded south-southeast of GAD, then proceeded in a northerly direction and when near 8A1, flew northeast of there. The
groundspeed remained about the same value from takeoff until 1652:33, where at that time the airplane was located about 3.2 nautical miles and 076 degrees
from the approach end of runway 21 at 8A1. Between 1652:33 and 1652:45, the ground speed slowed from 142 to 117 knots, and the aircraft altitude decrease
from 4,354 to 4,262 feet. The airplane proceeded in a northwesterly direction flying west of the extended runway centerline of runway 21 at 8A1, and after some
maneuvering, proceeded onto a straight in approach for runway 21. At about 1655:14, until the end of the recorded data at 1655:47, the airplane proceeded on
a southwesterly heading, and the ground speed slowed from 86 to 68 knots. At the last data point, the airplane was located approximately 754 feet and 023
degrees from the approach end of runway 21. A copy of the NTSB Vehicle Recorder Division GPS Factual Report and the tabular data are contained in the
NTSB public docket.
According to the NTSB Materials Laboratory Factual Report, examination of the upper securing hardware revealed wear patterns corresponding to the teeth of
the lock washer were observed on the faces of the nut and the flat washer. The clamp had more pointed corners, and had no step feature on the face that
clamped to the accessory housing. The remains of a gasket was measured and found to be 0.034 inch thick, while the thickness of the correct gasket is
specified to be 0.015 inch new, and when installed and clamped should have a thickness of approximately 0.010 inch. The lower flange of the magneto was
inspected and found to exhibit wear at the clamping face of the attachment flange and the adjacent surface. Inspection of the fractured piece of flange revealed
concentric crack arrest lines consistent with fatigue fracture emanated from an origin area near the middle of the fractured piece. A copy of the NTSB Materials
Laboratory Factual Report is contained in the NTSB public docket.
Lycoming Service Instruction No. 1508C, dated February 10, 2011, describes the attachment of magnetos on all Lycoming engines with dual magnetos. The
correct parts for attaching the magneto as described in SI 1508C are a nut part number (P/N) STD-1410, lock washer P/N STD-475), magneto clamp P/N
66M19385), and magneto gasket P/N LW-12681). Lycoming SI 1508C states that compliance with SI 1508C is mandatory and that failure to comply can cause
loss of engine power, although compliance is not mandatory for 14 CFR Part 91 operators. The time of compliance as stated in SI 1508C is at the next oil
change, not to exceed 50 hours of engine operation or at each magneto timing check or service. A copy of the service instruction is contained in the NTSB
public docket.
According to the Pilot's Operating Handbook (POH), in the event of a "Power Off Landing" for this airplane equipped with a backup gear extender, the
procedures call to lock the emergency gear lever in Override Engaged position before the airspeed drops to 122 miles-per-hour (mph) indicated airspeed to
prevent landing gear from inadvertently free falling. The same section also indicates to trim to maintain 106 mph, indicates the flaps are retracted, and to locate
a suitable field. The best glide chart indicates that based on the temperature (31 degrees Celsius), and altimeter setting of 29.98 inches of Mercury, the
approximate glide distance from the approximate altitude when the engine quit (4240 feet pressure altitude) to the runway elevation (600 feet pressure altitude),
would have resulted in a glide range of approximately 5 nautical miles. Excerpts of the POH are contained in the NTSB public docket.
A review of the maintenance records revealed the last annual inspection was signed off on February 18, 2011. The airplane total time at that time was recorded
to be 5,156.49 hours. The airplane total time at the time of the accident was recorded to be 5,176.26 hours. An excerpt from the maintenance records is
contained in the NTSB public docket.
A review of 14 CFR Part 91.409, revealed no person may operate an aircraft unless within the preceding 12 calendar months, it has had an annual inspection in
accordance with 14 CFR Part 43, and has been approved for return to service.
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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
Summary
The pilot/owner reported that, during the approach, he noted that the nose landing gear (NLG) indication light was not illuminated. He aborted the landing and
chose to fly by the air traffic control tower to have a controller check the position of the landing gear. An air traffic controller reported that the landing gear
appeared to be down. The airplane was then cleared to land, and, during the landing roll, the NLG collapsed, and the airplane came to rest on the runway.
Postaccident examination revealed that there was a hydraulic leak above the NLG actuator and that the NLG drag links were not secured in accordance with
the manufacturer's maintenance manual. Over 9 years before the accident, the manufacturer issued a mandatory service bulletin (SB) that required inspections
of the NLG, including inspection of the NLG actuator mounting bracket for cracks, elongation of the holes where the retraction link attaches, and loose mounting
rivets, and the lubrication of the NLG assembly at a frequency interval not to exceed 50 hours. Subsequently, the Federal Aviation Administration issued an
airworthiness directive (AD) requiring the actions contained in the SB. The postaccident examination also revealed that a microswitch appeared to have
recently been replaced; however, no associated maintenance entry was found during a review of the airplane's maintenance logbooks. The review did reveal
that the airplane's most recent annual inspection was performed about 2 years and 300 flight hours before the accident, that the AD was complied with at that
time, and that no defects were noted. No other entries regarding annual inspections or compliance with the SB or AD were noted. Therefore, it is likely that the
airplane was not in compliance with the SB or AD at the time of the accident, which likely resulted in the NLG being unable to operate properly and in its
collapsing on landing. If the airplane owner had maintained the airplane in accordance with the SB and AD, the hydraulic leak and the improperly secured NLG
drag links could have been detected and corrected, which could have prevented the NLG collapse.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot/owner's failure to
maintain the airplane in accordance with a mandatory service bulletin and an airworthiness directive, which resulted in the nose landing gear collapse during
landing.
Events
1. Landing-landing roll - Sys/Comp malf/fail (non-power)
1. Aircraft-Aircraft handling/service-Maintenance/inspections-Scheduled maint checks-Not serviced/maintained - C
2. Aircraft-Aircraft handling/service-Maintenance/inspections-Scheduled maint checks-Not inspected - C
3. Personnel issues-Task performance-Maintenance-Scheduled/routine maintenance-Owner/builder - C
4. Aircraft-Aircraft systems-Landing gear system-Nose/tail landing gear-Failure - C
5. Aircraft-Aircraft systems-Landing gear system-Nose/tail landing gear-Failure - C
6. Aircraft-Aircraft systems-Landing gear system-Nose/tail landing gear-Incorrect service/maintenance - C
7. Personnel issues-Task performance-Record-keeping-Aircraft/maintenance logs-Pilot
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.
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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.
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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03/16/2015 815 MDT
Regis# N4785F
Boulder, CO
Acft Mk/Mdl PIPER PA18 - 150
Acft SN 18-7906
Eng Mk/Mdl LYCOMING O-360-A3A
Acft TT
Fatal
Opr Name: SOARING SOCIETY OF BOULDER INC
Opr dba:
14829
0
Apt: Boulder Municipal KBDU
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Summary
While conducting a flight to practice landings in a tailwheel equipped airplane, the pilot made an approach to the runway. During the landing, the airplane
touched down on the runway and bounced. The pilot attempted to regain control of the airplane as it touched down several times. The airplane exited the right
side of the runway onto the grass and the left wing struck an embankment. A postaccident examination revealed the airplane sustained substantial damage to
the left wing and aileron. The pilot reported no mechanical malfunctions or failures with the airplane prior to the accident that would have precluded normal
operation of the airplane.
Cause Narrative
control during a bounced landing, which resulted in a runway excursion.
Events
1. Landing-flare/touchdown - Abnormal runway contact
Narrative
While conducting a flight to practice landings in a tailwheel equipped airplane, the pilot made an approach to the runway. During the landing, the airplane
touched down on the runway and bounced. The pilot attempted to regain control of the airplane as it touched down several times. The airplane exited the right
side of the runway onto the grass and the left wing struck an embankment. A postaccident examination revealed the airplane sustained substantial damage to
the left wing and aileron. The pilot reported no mechanical malfunctions or failures with the airplane prior to the accident that would have precluded normal
operation of the airplane.
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02/15/2015 1030 CST Regis# N7181S
Asherton, TX
Apt: N/a
Acft Mk/Mdl ROBINSON HELICOPTER R22 BETA-BETA Acft SN 3008
Eng Mk/Mdl LYCOMING O&VO-360 SER
Fatal
Opr Name: SOUTHWEST TEXAS HELICOPTERS,
INC
0
Ser Inj
Opr dba:
0
Aircraft Fire: NONE
AW Cert: STN
Summary
According to the pilot, he was herding cattle with the helicopter. He descended to an altitude of about 10 feet to get the cattle to turn and enter a pen. After the
cattle entered the pen, he maneuvered away and gained altitude to clear some nearby trees. The pilot thought the helicopter was clear of the trees; however,
the tailrotor impacted a tree. The helicopter started to spin, so he reduced the throttle to stop the spin. The helicopter impacted terrain, resulting in substantial
damage the main rotor blades, fuselage, and tailboom.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot did not maintain
adequate clearance from the trees.
Events
1. Maneuvering-low-alt flying - Collision with terr/obj (non-CFIT)
2. Maneuvering-low-alt flying - Low altitude operation/event
1. Personnel issues-Action/decision-Action-Incorrect action selection-Pilot - C
2. Environmental issues-Physical environment-Object/animal/substance-Tree(s)-Not specified
Narrative
According to the pilot, he was herding cattle with the helicopter. He descended to an altitude of about 10 feet to get the cattle to turn and enter a pen. After the
cattle entered the pen, he maneuvered away and gained altitude to clear some nearby trees. The pilot thought the helicopter was clear of the trees; however,
the tailrotor impacted a tree. The helicopter started to spin, so he reduced the throttle to stop the spin. The helicopter impacted terrain, resulting in substantial
damage the main rotor blades , fuselage, and tailboom.
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Accident Rpt# WPR15CA043
11/15/2014 1600 MST Regis# N32VH
Prescott, AZ
Apt: N/a
Acft Mk/Mdl ROBINSON HELICOPTER R22 BETA-II
Acft SN 3930
Acft TT
Fatal
Opr Name: GUIDANCE ACADEMY, LLC
Opr dba: GUIDANCE AVIATION
1085
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Events
1. Autorotation - Hard landing
Narrative
During an instructional flight, the certified flight instructor (CFI) was demonstrating a 180-degree autorotation for a pilot rated student. The CFI positioned the
helicopter on a downwind, abeam the landing site, about 800 feet above ground and at about 70 knots when he started a right turning autorotation. After turning
about 80 degrees the pilot rated student told the CFI that it appeared they were going to land short on the approach. The CFI increased the helicopter's turn
rate; however, near the end of the turn, he noticed the rotor RPM was starting to decay and he applied down collective. As the helicopter was rolling out of the
turn, it appeared that the helicopter was descending faster than moving forward. The CFI began the cyclic flare to reduce the descent; however, the helicopter
impacted the ground hard and rolled onto its left side. The helicopter sustained substantial damage to the tailboom and fuselage structure. The CFI reported
there were no mechanical malfunctions or failures that would have precluded normal operations.
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07/02/2014 1500 CDT Regis# N225TV
Acft Mk/Mdl ROBINSON HELICOPTER
Acft SN 0253
Opr Name: KC COPTERS
Olathe, KS
Apt: Johnson County Executive OJC
Fatal
0
Ser Inj
Opr dba:
0
Aircraft Fire: NONE
AW Cert: STN
Summary
The pilot reported he landed at the airport without incident. During engine shutdown, he applied rotor brake to slow the main rotor blades. When the pilot
released the brake, he heard a bang and felt an impact to the aircraft on the rear left side. He reapplied the main rotor brake intermittently until the blades
stopped. The pilot exited the aircraft and noticed a tail boom strike occurred. He stated he input aft cyclic during landing to accommodate landing slightly
downhill and did not place the controls in neutral during shutdown. According to the manufacture's shutdown procedures, the cyclic and pedals should be in the
neutral position.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's failure to follow the
manufacturer's engine shutdown procedure.
Events
1. Standing-engine(s) shutdown - Miscellaneous/other
1. Personnel issues-Task performance-Use of equip/info-Use of policy/procedure-Pilot - C
Narrative
The pilot reported he landed at the airport without incident. During engine shutdown, he applied rotor brake to slow the main rotor blades. When the pilot
released the brake, he heard a bang and felt an impact to the aircraft on the rear left side. He reapplied the main rotor brake intermittently until the blades
stopped. The pilot exited the aircraft and noticed a tail boom strike occurred. He stated he input aft cyclic during landing to accommodate landing slightly
downhill and did not place the controls in neutral during shutdown. According to the manufacture's shutdown procedures, the cyclic and pedals should be in the
neutral position.
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09/15/2014 2130 UTC Regis# N9844N
Acft Mk/Mdl ROBINSON HELICOPTER
Acft SN 0450
Opr Name: BRYANT DUSSETSCHLEGER
Beaumont, TX
Apt: Jack Brooks Rgnl BPT
Fatal
0
Ser Inj
Opr dba:
0
Aircraft Fire: NONE
AW Cert: STN
Summary
According to the pilot's statement, he made a radio call he was entering left base of the traffic pattern for the runway. He heard another radio call for an airplane
taxiing to the runway and saw the airplane approaching the run-up area. The pilot made a radio call he was turning onto final for the runway. He saw the other
airplane move toward the runway hold short line and he made another announcement he was on final approach for the runway. As he approached the runway
end, the other airplane "nosed over the line." During the landing flare at midfield, the other aircraft made a radio call to takeoff on the runway. The pilot
attempted to depart the runway area for the taxiway. As he turned the helicopter toward the taxiway, he felt the helicopter "swing hard and turn," then begin to
spin. The pilot stated he lost control and landed hard "crushing" the skids.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's loss tail rotor
effectiveness while attempting a taxiway side-step during landing. Contributing to the accident was another pilot's failure to ensure the runway was clear before
occupying the runway for takeoff.
Events
1. Takeoff - Loss of tail rotor effectiveness
2. Personnel issues-Action/decision-Action-Incorrect action selection-Pilot of other aircraft - F
Narrative
According to the pilot's statement, he made a radio call he was entering left base of the traffic pattern for the runway. He heard another radio call for an airplane
taxiing to the runway and saw the airplane approaching the run-up area. The pilot made a radio call he was turning onto final for the runway. He saw the other
airplane move toward the runway hold short line and he made another announcement he was on final approach for the runway. As he approached the runway
end, the other airplane "nosed over the line." During the landing flare at midfield, the other aircraft made a radio call to takeoff on the runway. The pilot
attempted to depart the runway area for the taxiway. As he turned the helicopter toward the taxiway, he felt the helicopter "swing hard and turn," then begin to
spin. The pilot stated he lost control and landed hard "crushing" the skids.
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07/04/2014 1405 CDT Regis# N4263
Acft Mk/Mdl SLAUGHTER MIKE CH601-HDS-HDS
Opr Name: BUSTER GARY C
Acft SN 6-1859
Frankston, TX
Apt: N/a
Fatal
0
Ser Inj
Opr dba:
1
Aircraft Fire: NONE
AW Cert: UNK
Events
2. Maneuvering-low-alt flying - Aerodynamic stall/spin
Narrative
On July 4, 2014, at 1405 central daylight time, a Slaughter CH601-HDS ultralight airplane, N4263, impacted Lake Palestine, Texas, near Frankston, Texas,
while maneuvering at low altitude. The pilot was seriously injured and the passenger received minor injuries. The airplane was substantially damaged. The
airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological
conditions prevailed at the time of the accident, and no flight plan had been filed. The flight originated from Mineola Airport (3F9), Mineola, Texas, and was en
route to Aero Estates Airpark (T25), Frankston, Texas.
According to statements provided to FAA Inspectors and law enforcement officers, the pilot and his son were returning to T25 after attending a fly-in at 3F9.
The son said that during their descent to T25, the pilot spotted a boat and began to follow it at low altitude. The pilot then made a steep turn and stalled the
airplane, lost control, and impacted the water. The pilot and passenger were rescued by nearby boaters.
The wreckage remained in the lake and was not available for examination. Neither occupant indicated there were any system malfunctions with the airplane
prior to the accident and indicated fuel exhaustion did not occur.
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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
Summary
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.
Cause Narrative
directional control during the landing roll.
Events
2. Landing-aborted after touchdown - Runway excursion
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.
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General Aviation Reports

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