Monday, February 16, 2015

Piper Warrior PA28 -161, N9089N, General Aviation Inc: Accident occurred August 29, 2013 in Danville, Virginia

NTSB Identification: ERA13FA385
14 CFR Part 91: General Aviation
Accident occurred Thursday, August 29, 2013 in Danville, VA
Probable Cause Approval Date: 02/12/2015
Aircraft: PIPER PA-28-161, registration: N9089N
Injuries: 1 Fatal.

NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.


Several eyewitnesses reported observing the airplane performing several takeoffs and landings. One witness stated that, during one landing attempt, the airplane was low, that a go-around maneuver was initiated, and that the airplane banked sharply left and right during the maneuver. The witness reported that the second landing attempt was successful and that the airplane was then taxied back to the beginning of the runway for another takeoff. During the accident approach, the airplane was observed flaring too high and banking left. One witness stated that the pilot added power and categorized the subsequent climbout as very shallow just before the airplane impacted an antenna and terrain. A postimpact fire ensued. Examination of the wreckage revealed no abnormalities or malfunctions that would have precluded normal operation.


Review of flight school records revealed that the student pilot's first solo flight was 4 days before the accident and that the flight was 0.8 hour long. It could not be determined if the first solo flight was considered the student pilot's supervised solo or if the accident flight was considered the supervised solo. The flight school's standard operating procedure was to "completely go through all requirements twice"; therefore, although the accident flight was the student pilot's second solo flight, it should still have been supervised by the flight instructor.


The flight instructor reported that the student pilot was scheduled to fly about an hour earlier than when the accident flight initiated; however, due to work requirements, the student pilot had to delay the flight. The flight instructor stated that the student was "upset" about the delay. He said that they conducted three takeoffs and landings together, which took about 30 minutes, and that he then exited the airplane for the student pilot's solo flight. The flight instructor reported that, when the student pilot departed on the solo flight, he witnessed a "beautiful" landing and then went inside to check on another student. He subsequently observed the student pilot conduct more landings, which he categorized as "good."


A cell phone was located inside a thermally damaged case. The cell phone was found off; however, when activated, it indicated that a missed call occurred around the time of the accident. According to the manufacturer, the cell phone may overheat and shut down when exposed to high temperatures and will not register a call when powered off. Therefore, it is likely that the cell phone was on and that the pilot was aware of the incoming call when it was received. Although the investigation could not determine if the student pilot had become distracted by a cell phone call, the flight instructor further stated that the student was very focused on learning but that he was distracted when his cell phone rang. However, the flight instructor did not require the pilot to turn the cell phone off during flight. The flight instructor was in a position of authority and operational control and should have taken steps to ensure that the student was not distracted by the cell phone while flying.


The National Transportation Safety Board determines the probable cause(s) of this accident as follows:

The student pilot's failure to maintain control and climb the airplane during a go-around maneuver. Contributing to the accident was the flight instructor's failure to provide adequate oversight of the student pilot by ensuring that the cockpit was free of distractions.

HISTORY OF FLIGHT

On August 29, 2013, about 1945 eastern daylight time, a Piper PA-28-161, N9089N, was destroyed when it impacted an on airport instrument landing system (ILS) glide slope antenna, the ground, and then a postaccident fire ensued at Danville Regional Airport (DAN), Danville, Virginia. The student pilot, was fatally injured. Visual meteorological conditions prevailed and no flight plan was filed for the local solo flight which was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.

According to several eyewitnesses, the airplane was observed performing repeated takeoffs and landings to runway 2. During one of the landing attempts the airplane "appeared too low;" the airplane's engine power could be heard increasing, and a go-around maneuver commenced. During the initial go-around the airplane rolled "sharply left…then sharply right" before it began to climb out. On the second attempt, the landing was "normal" and the airplane taxied back to the beginning of the runway for takeoff. During the accident approach, the airplane "flared high, then rolled left" and then began to climbout "very shallow" and "appeared level" prior to impacting the antenna. The witnesses reported hearing the engine power increase and just prior to impacting the antenna and then engine power decreased.

Based on certificated flight instructor (CFI) and eyewitness interviews the actual number of landing attempts could not be conclusively determined.

PERSONNEL INFORMATION

According to Federal Aviation Administration (FAA) and General Aviation Flight, Inc., the flight school, the pilot, age 42, held a student pilot certificate dated August 14, 2013, which was also a third-class medical certificate. At the time of certificate issuance, the student pilot reported 8.8 total flight hours. Although, at the time of this writing the student pilot's logbook had not been located, flight school records showed the student had accumulated about 13 total flight hours, of which, an estimated 1.6 of those hours were solo flight. The student's first flight was accomplished on June 24, 2013. The first solo flight recorded in the flight school's record was on August 25, 2013 and was 0.8 hours in duration. The flight school documentation further stated "SOP [Standard Operating Procedure] is to completely go through all requirements twice and then to review selected ones as per student needs and desires."

AIRCRAFT INFORMATION

According to FAA records, the airplane was issued an airworthiness certificate on December 11, 1986, and was registered to General Aviation, Inc on December 5, 1986. It was powered by a 160-hp Lycoming O-320-D3G engine, serial number RL-13625-39E, driving a Sensenich 2-bladed propeller. The airplane's most recent inspection, noted as an annual inspection in the logbook, was accomplished on August 6, 2013. At the time of that inspection the airplane had 13,976.8 total hours of time in service. The engine's most recent inspection, noted as a 100-hour inspection in the logbook, was accomplished on August 6, 2013, at 4,211.1 hours of total time in service and 1,876.2 total hours since major overhaul with a recorded tachometer time of 13,976.8 hours.

At the time of the inspections the tachometer was recorded as 3,976.8 hours. Prior to the accident flight the aircraft tachometer was recorded as 4020.6 hours.

The most recent recorded fueling was accomplished on August 27, 2013, at DAN. The airplane had been fueled with 20.1 gallons of fuel.

METEOROLOGICAL INFORMATION

The 1953 recorded weather observation at DAN included wind from 050 degrees at 5 knots, 10 miles visibility, clear skies, temperature 26 degrees C, dew point 21 degrees C; altimeter setting 29.99 inches of mercury.

On the day of the accident, official sunset was at 1950, end of civil twilight was at 2016.

AIRPORT INFORMATION

The airport was a publically owned airport and at the time of the accident did not have a control tower. There were two runways designated runway 2/20, and runway 13/31. However, at the time of the accident, the airport was under construction and runway 13/31 was closed. Runway 2/20 was normally 6,502 feet long; however, due to construction, it was 3,028 feet long and 150 feet wide. The airport elevation was 571 feet above mean sea level. The ILS glide slope antenna was located about 900 feet from the runway threshold to runway 2 and about 175 feet from the west side of the paved portion of runway 2/20.

The airport, at the time of the accident had numerous published Notices to Airman (NOTAM) and some of them that affected the landing runway were:

• DAN 06/009 DAN RWY 2/20 RWY LGTS PCL OTS EXC LOW INTST
• DAN 04/007 DAN RWY 2/20 NORTH 3474 CLSD WEF 1304251528
• DAN 03/040 DAN RWY 2/20 CLSD TO ACFT WITH APCH SPEED IN EXCESS OF 121 KTS
• DAN 03/035 DAN RWY 2/20 CLSD TGL
• DAN 03/027 DAN RWY 20 PAPI OTS
• DAN 03/026 DAN RWY 2 PAPI OTS
• DAN 03/021 DAN NAV ILS RWY 2 OM OTS WEF 1303251200-1401151200
• DAN 03/017 DAN NAV ILS RWY 2 GP/LLZ OTS WEF 1303251200
• DAN 03/016 DAN RWY 2 ALS OTS WEF 1303251200
• DAN 03/015 DAN RWY 2 REIL OTS WEF 1303251200

WRECKAGE AND IMPACT INFORMATION

The ILS glide slope antenna exhibited impact damage 39.5 feet above ground level (agl). Ground scars were present between the runway and taxiway "A." The left wing was collocated with the ILS glide slope antenna. The accident flight path was oriented on a 346 degree heading and the debris path began about 20 feet prior to ILS glide slope antenna and consisted of the left wing beginning at the wing root and included the entire wing. The debris path terminated 176 feet past the antenna. The debris path included a ground scar in a position consistent with the right wing impacting the ground in a right wing low attitude. The impact mark was located 105 feet from the antenna. Two propeller strike marks were also located along the debris path. The marks were 31 inches apart and the first strike mark was about 5 inches in depth. The second mark consisted of the propeller assembly including both blades and the propeller hub. The main wreckage came to rest on a heading of 129 degrees.

Nose and Cockpit Section

The engine and cockpit exhibited fore-to-aft crushing and thermal damage. The engine remained attached to the firewall via the tubular mounts. The propeller was found separated from the engine and was located along the debris field and one of the blades, which was imbedded in the ground, exhibited minimal S-bending and leading edge damage. The ignition switch was found with the key remaining in it; however, due to thermal damage it could not be determined on the actual position. The fuel selector valve remained attached to the side wall; however, due to thermal damage the position of the switch could not be determined. According to the CFI, the selector valve was likely in the "LEFT" position when he exited the airplane prior to the student departing on the solo flight just prior to the accident. Both front seats remained attached to their respective seat tracks. The rear seats remained attached to their attach points. The left shoulder harness buckle remained attached the left side of the belt buckle. One side of the seat belt in the rear seat remained attached to the fuselage structure; however, no other seatbelts or buckles were located. The flap lever, located between the two pilot seats, was in the bottom detent, which correlated to the flaps "UP" position, which also correlated to the flap position found on both wings. The main entry located on the right side of the airplane was thermally damaged; however, the door latch was in the locked position.

A cellular phone was located in the wreckage, in a carrying case, and the case had extensive thermal damage. Removing the phone from the case revealed it was not on; and after it was turned on for examination it revealed that a missed call was received at 1946 EDT. According to the cellular phone manufacturer's online technical support, the model of phone found in the wreckage may overheat and shutdown when exposed to temperatures that exceed 35 degrees C; and it will not register a missed call when powered off.

Engine

Engine continuity was confirmed from the propeller hub to the rear accessory pad via hand rotation of the propeller flange. Thumb compression was confirmed on all cylinders during hand rotation. The top and bottom spark plugs were removed, appeared to be light gray in color, and were "normal" in wear according to Champion Spark Plug Guide. The bottom spark plugs associated with the Nos. 2 and 4 cylinder were oily to the touch. Due to thermal damage, neither magneto was able to produce spark but the impulse coupling had positive contact that was heard when rotated by hand. The fuel pump was disassembled and no noted anomalies were found with the check valve, and all gaskets exhibited thermal damage. Examination of the fuel pump actuator rod revealed that it was able to be operated by hand. The oil filter, which was thermally damaged, was removed from the engine and disassembled. The filter media was removed for examination and no metal material was found. The oil suction screen was removed and was free of debris. The vacuum pump was removed and rotated by hand, it was disassembled, and the carbon vanes remained intact. The throttle and mixture control arm positions were unreliable due to impact and thermal damage.

Right Wing

The right wing remained attached to the fuselage and exhibited impact crush damage and thermal damage at the wing root. The wing tip also exhibited impact crush damage in the negative direction beginning at the wing tip and proceeding inboard 66 inches. The flap was in the retracted or flaps "UP" position. The aileron remained attached to the wing at its wing attach point. Cable continuity was confirmed from the control yoke to the right aileron as well as the cross aileron cable, which also remained attached to the left wing's aileron bell crank. The aileron bell was found separated from the left wing; however, remained attached to both aileron cables. The right wing's fuel cap remained attached, seated correctly, and locked in position. The fuel tank contained a blue fluid with similar smell and color as 100 LL Aviation fuel. The right main landing gear remained attached to the wing attach points.

Tail Section

The rudder and stabilator remained attached to the empennage; however, the top of the rudder and the vertical stabilizer had impact damage. Cable continuity was confirmed from the base of the rudder pedals to the rudder; however, examination of the cables revealed they were off their associated pulley located in the rear of the tail section. There was no gouge or wear marks on the cables that would indicate the cables were off the pulley prior to the accident sequence. The stabilator counter weight remained intact. Elevator cable continuity was confirmed from the base of the control column to the elevator bellcrank; however, similar to the rudder, the cables were found off the pulley. There was no gouge or wear marks on the cables that would indicate the cables were off the pulley prior to the accident sequence. The pitch trim was found with five threads exposed on the bottom, which measured 11/16 of an inch of exposed threads, that correlated to a neutral trim position.

Left Wing

The left wing exhibited crush and impact damage beginning at the wing root and proceeding outward, with the larger area of damage concentrated at the wingroot. The fuel tank was breached, devoid of fuel, and the fuel cap remained secured and seated. The flap remained attached and was found in the retracted or "UP" position. The aileron bellcrank was separated from the wing attach point but did remain attached to the cable and continuity was confirmed from the base of the control column, through the separation, to the aileron. The aileron remained attached to the associated attach points. The stall micro-switch remained attached on the leading edge of the wing. The micro-switch was removed from the wing and continuity was confirmed using a multimeter when the switch was moved by hand to close the contact. The left main landing gear remained attached; however, an angle iron was found penetrating the inboard wall of the tire approximately 2 inches from the brake assembly and the tire was found deflated.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot on August 30, 2013, by the Office of the Chief Medical Examiner, Roanoke, Virginia. The autopsy listed the cause of death as "inhalation of smoke and thermal injuries," and the report listed the specific injuries.

Forensic toxicology was performed on specimens from the pilot by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The toxicology report stated neither ethanol or carbon monoxide were detected, and Amlodipine was detected in the urine and the blood; however, no quantified amount was provided.

According to the FAA Aerospace Medical Research Forensic Toxicology website, Amlodipine is a calcium channel blocker heart medication used in the treatment of hypertension.

ADDITIONAL INFORMATION

Interview with CFI

In a recorded interview, the CFI stated that the day of the accident the student pilot was scheduled to fly at 1730; however, due to work requirements taking longer than anticipated, the student pilot had to delay the flight. The CFI described the student pilot as upset that the flight was going to be delayed. The CFI reported that the student pilot was a medical doctor and that the day of the accident a "procedure" took longer than anticipated. He further reported that the student pilot's patient, while performing the "procedure," almost expired.

Upon arrival at the airport, the CFI and student pilot flew three takeoffs and landings, for about a half an hour, prior to the CFI exiting the airplane and the student pilot conducting a solo flight. The CFI informed the student pilot not to exceed eight takeoffs and landings so the student pilot would not "get fatigued." The CFI further stated that he watched the student pilot's first landing, which he categorized as "beautiful," and then went inside the building to check on another student, came back out and "saw another good landing," went back inside the building, came back out, got on a golf cart, "saw a couple of more good landings." The golf cart was positioned on the taxiway, in order for the student pilot to see it and terminate the takeoff and landing practice as it was "time to put the airplane up." The CFI then observed the airplane "a little bit low," heard the engine increase in power, and observed the airplane level off, banked, and impact the glideslope antenna. The CFI further stated that the student pilot was very focused on flying; however, when his pager or cellular phone sounded, he would immediately reach for it. The CFI provided an example of, while in the airport traffic pattern, the CFI's cellular phone "went off" the student "…started looking like it was for his." The CFI further stated that "It's my cell phone. Forget it. And he [the student] looked at me like, forget the cell phone? He couldn't imagine somebody just ignoring a cell phone." The CFI estimated the student performed five landings prior to the accident.

Aeronautical Information Manual (AIM)

According to the Aeronautical Information Manual (AIM), a pilot can self-assess his ability to fly by applying a personal checklist known as IMSAFE. The acronym stands for Illness, Medication, Stress, Alcohol, Fatigue, and Emotion. The AIM stated that "Stress and fatigue can be an extremely hazardous combination…" The AIM also stated that "the emotions of anger, depression, and anxiety…not only decrease alertness but also may lead to taking risks…any pilot who experiences an emotionally upsetting event should not fly until satisfactorily recovered from it."

Fatigue in Aviation, Medical Facts for Pilots

According to a pilot safety brochure produced by the FAA's Civil Aerospace Medical Institute, Fatigue in Aviation, Medical Facts for Pilots (OK-07-193) states in part, "Fatigue leads to a decrease in your ability to carry out tasks…significant impairment in a person's ability to carry out tasks that require manual dexterity, concentration, and higher-order intellectual processing. Fatigue may happen…in a relatively short time (hours) after some significant physical or mental activity…"

Aviation Instructor's Handbook (FAA-H-8083-9A)

According to Chapter 7 "Instructor Responsibilities and Professionalism" under the section titled "Aviation Instructor Responsibilities" indicates five main responsibilities of aviation instructors. Those responsibilities are listed as "Helping Students learn. Providing adequate instruction. Demanding adequate standards of performance. Emphasizing the positive. Ensuring aviation safety." The chapter further explains that there are at least eight "Additional Responsibilities of Flight Instructors" and two of those responsibilities are "Pilot supervision" and "Student's pre-solo flight thought process."

According to Chapter 8 "Techniques of Flight Instruction" in the section titled "First Solo Flight" states in part "During the student's first solo flight, the instructor must be present to assist in answering questions or resolving any issues that arise during the flight. To ensure the solo flight is a positive, confidence-building experience for the student, the flight instructor needs to consider time of day when scheduling the flight…If possible, the flight instructor needs access to a portable radio during any supervised solo operations. A radio enables the instructor to terminate the solo operation if he or she observes a situation developing…"

Although the FAA does not specifically state everything that a CFI is responsible for; FAA approved courses do provide some specific guidance when it comes to professionalism. Some of the responsibilities taught under those courses are:

AMERICAN FLYERS FLIGHT INSTRUCTOR REFRESHER COURSE

Stage 1, Chapter 3 "Instructor Professional Responsibilities" states in part "…Although the word 'professionalism' is widely used, it is rarely defined. Though not all-inclusive, the following list gives some major considerations and qualification that should be included in the definition of professionalism.
• Professionalism exists only when a service is performed for someone or for the common good.
• Professionalism is achieved only after extended training and preparation
• True performance as a professional is based on study and research
• Professionals must be able to reason logically and accurately
• Professionalism requires the ability to make good judgmental decisions. Professionals cannot limit their actions and decisions to only standard patterns and practices
• Professionalism demands a code of ethics. Professionals must be true to themselves and to those they serve. Anything less than a sincere performance is quickly detected and immediately destroys their effectiveness."

The chapter goes onto state "Training Oversight and Student Supervision – Flight Instructors have the responsibility to provide guidance and restraint with respect to the solo operations of their students. This is by far the most important flight instructor responsibility because the instructor is the only person in a position to make the determination that a student is ready for solo operations…"

GLEIM FLIGHT INSTRUCTOR REFRESHER COURSE STUDY UNIT 9

According to Section 9.3 "Instructor Responsibilities" states in part "I. Student Pilot Supervision…B. Flight instructors have a moral and ethical obligation to provide guidance and restraint with respect to the solo operations of their student…"



Scott J. Banuelos, MD



Danville, VA-- There is now more information on the plane crash at Danville Regional Airport that left a student pilot dead in 2013.


35-year-old Dr. Scott Banuelos was killed. The National Transportation Safety Board said in their final report that Banuelos failed to maintain control and climb the airplane during a go-around maneuver. It also said the flight instructor failed to provide adequate oversight of the student pilot by ensuring the cockpit was free of distractions.


They believe a cell phone call during the flight may have been a major distraction.











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