Monday, December 12, 2016

Loss of Control in Flight: Beech A36 Bonanza, N776WM; accident occurred December 12, 2016 in New Smyrna Beach, Volusia County, Florida


Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Orlando, Florida

Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf

Investigation Docket - National Transportation Safety Board:https://dms.ntsb.gov/pubdms 


http://registry.faa.gov/N776WM 


Location: New Smyrna Beach, FL
Accident Number: ERA17CA068
Date & Time: 12/12/2016, 1530 EST
Registration: N776WM
Aircraft: BEECH A36
Aircraft Damage: Substantial
Defining Event: Loss of control in flight
Injuries: 1 Minor
Flight Conducted Under: Part 91: General Aviation - Personal

Analysis 

Passengers reported that, during a winter flight, cold air was entering the airplane from the left side of the passenger cabin. Afterward, the pilot examined the area and discovered that there was a small gap under the emergency exit window that was allowing air to enter the cabin from outside the airplane. He opened the window and examined the rubber seal, which was intact. However, he could not tell if it was compressed or thinner than normal. He then closed and latched the window and inspected the latch with a flashlight to make sure it was latched. Because he was going to fly back to his home airport in similar winter conditions on the next flight, he took several rolled-up paper towels and placed them between the trim and the window to try and keep the cold air out and placed a strip of blue painter's tape on the outside of the lower portion of the window to further reduce the entry of cold air. He decided to fly the airplane once around the traffic pattern before fueling up for his return flight. After takeoff and while on the downwind leg of the traffic pattern at 800 ft, he suddenly heard a "whoosh" behind his seat. Instead of landing and checking to see what happened, he checked for other traffic, turned on the autopilot, in heading and altitude mode, then reached around behind him to shut and latch the window, which had opened 2 to 3 inches. Seconds later, after turning back around to his normal seated position, he heard a loud "pop" and turned around and saw that the window had opened completely. Given that he was afraid it would come off the airplane and strike the tail, he reached back again and pulled the window down. The pilot reported that he must have "bumped" the autopilot off while he was doing this, because when he looked forward to check for traffic, he noticed that the airplane was approaching the ground. He then banked left and right to determine his location and spot any obstacles, raised the nose, and added power to climb. He then noticed that there were power lines slightly higher than his altitude directly in front of him, and rather than risk a possible stall close to the ground by pulling back suddenly, he lowered the nose and "put" the airplane on the ground. The airplane then struck trees, and a fire ensued, which resulted in substantial damage to the airframe. Examination of the emergency exit window by a Federal Aviation Administration inspector revealed that the paper towels the pilot inserted in the gap between the window and the airframe were interfering with the window's latching mechanism.

Probable Cause and Findings

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

The pilot's inappropriate response to an emergency exit window opening in flight, which resulted in a loss of control, precautionary off-airport landing, and subsequent impact with trees. Contributing to the accident was the pilot's improper repair of the emergency exit window before the flight.

Findings

Aircraft

Emergency exit - Incorrect service/maintenance (Factor)
Altitude - Not attained/maintained

Personnel issues
Incorrect action performance - Pilot (Cause)
Use of equip/system - Pilot (Cause)
Aircraft control - Pilot (Cause)
Repair - Pilot (Factor)

Environmental issues
Tree(s) - Contributed to outcome

Factual Information


History of Flight


Prior to flight

Miscellaneous/other

Approach-VFR pattern downwind
Miscellaneous/other
Loss of control in flight (Defining event)

Emergency descent
Off-field or emergency landing

Landing
Off-field or emergency landing

Landing-landing roll

Collision with terr/obj (non-CFIT)

Post-impact

Fire/smoke (post-impact)


Pilot Information

Certificate: Airline Transport; Commercial
Age: 61, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): Airplane Multi-engine; Airplane Single-engine; Instrument Airplane
Toxicology Performed: No
Medical Certification: Class 1 With Waivers/Limitations
Last FAA Medical Exam: 11/10/2016
Occupational Pilot: Yes
Last Flight Review or Equivalent: 11/04/2016
Flight Time:  15881 hours (Total, all aircraft), 173 hours (Total, this make and model), 13000 hours (Pilot In Command, all aircraft), 116 hours (Last 90 days, all aircraft), 30 hours (Last 30 days, all aircraft) 

Aircraft and Owner/Operator Information


Aircraft Make: BEECH
Registration: N776WM
Model/Series: A36 UNDESIGNATED
Aircraft Category: Airplane
Year of Manufacture: 1983
Amateur Built: No
Airworthiness Certificate: Utility
Serial Number: E-2088
Landing Gear Type: Retractable - Tricycle
Seats: 6
Date/Type of Last Inspection: 02/17/2016, Annual
Certified Max Gross Wt.: 4003 lbs
Time Since Last Inspection: 130 Hours
Engines: 1 Reciprocating
Airframe Total Time: 3451 Hours at time of accident
Engine Manufacturer: Continental
ELT: C126 installed, activated, did not aid in locating accident
Engine Model/Series: IO-550-B
Registered Owner: On file
Rated Power: 300 hp
Operator: On file
Operating Certificate(s) Held: None 


Meteorological Information and Flight Plan


Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: EVB, 10 ft msl
Distance from Accident Site: 5 Nautical Miles
Observation Time: 1550 EST
Direction from Accident Site: 90°
Lowest Cloud Condition: Scattered / 2500 ft agl
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 10 knots /
Turbulence Type Forecast/Actual: / None
Wind Direction: 270°
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 30.06 inches Hg
Temperature/Dew Point: 26°C / 19°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: New Smyrna Beach, FL (7FL6)
Type of Flight Plan Filed: None
Destination: New Smyrna Beach, FL (7FL6)
Type of Clearance: None
Departure Time: 1520 EST
Type of Airspace: Class G

Airport Information


Airport: SPRUCE CREEK (7FL6)
Runway Surface Type: N/A
Airport Elevation: 23 ft
Runway Surface Condition: Unknown
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: None

Wreckage and Impact Information


Crew Injuries: 1 Minor
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Minor
Latitude, Longitude: 29.051944, -81.035278 (est)


NTSB Identification: ERA17CA068
14 CFR Part 91: General Aviation
Accident occurred Monday, December 12, 2016 in New Smyrna Beach, FL
Aircraft: BEECH A36, registration: N776WM
Injuries: 1 Minor.

NTSB investigators used data provided by various entities, including, but not limited to, the Federal Aviation Administration and/or the operator and did not travel in support of this investigation to prepare this aircraft accident report.


During a winter flight, passengers reported that cold air was entering the airplane from the left side of the passenger cabin. Afterwards, the pilot examined the area and discovered that there was a small gap under the emergency exit window that was allowing air to enter the cabin from outside the airplane. He opened the window and examined the rubber seal which was intact. He could not tell though, if it was compressed or thinner than normal. He then closed and latched the window and inspected the latch with a flashlight to make sure it was latched. Since he was going to fly back to his home airport in similar winter conditions on the next flight, He took several rolled-up paper towels and placed them between the trim and the window to try and keep the cold air out, and placed a strip of blue painters tape on the outside of the lower portion of the window to further reduce the entry of cold air. 

Since it was a beautiful day, he decided to fly the airplane once around the traffic pattern before fueling up for his return flight. After takeoff while on the downwind leg of the traffic pattern at 800 feet, he suddenly heard a "whoosh" behind his seat. Instead of landing, and then checking to see what happened, he instead checked for other traffic, turned on the autopilot, in heading and altitude mode, then reached around behind him to shut and latch the window which had opened 2 to 3 inches. Moments later, after turning back around to his normal seated position, he then heard a loud "pop" and turned around to find that the window had now opened completely. Since he was afraid it would come off the airplane and strike the tail, he reached back once again and pulled the window back down.

The pilot advised that he must have "bumped" the autopilot off while he was doing this, since when he looked forward to check for traffic, he noticed that the airplane was approaching the ground. He then banked left and right to determine his location and spot any obstacles, raised the nose, and added power to climb. He then noticed that there were powerlines slightly higher than his altitude directly in front of him, and rather than risk a possible stall close to the ground by pulling back suddenly, he lowered the nose and "put" the airplane on the ground. At this point the airplane was approaching the edge of a field bordered by trees, so he pointed the nose of the airplane between trees. The airplane then struck the trees, and a fire ensued, resulting in substantial damage to the airframe. Examination of the emergency exit window by a Federal Aviation Administration inspector revealed that the paper towels the pilot inserted in the gap between the window and the airframe were interfering with the window's latching mechanism.





















AIRCRAFT: 1983 Beech A36 Bonanza N776WM, s/n: E-2088

Last annual inspection was accomplished on 02/17/16 at Tach 1650.6, Hobbs 1092.5 and AFTT 3320.9.  The current Hobbs reads 1104.6
                                                              
ENGINE:    Continental IO-550-B, s/n: 675060

Overhauled on 11/25/1996 at ETT 1590.1 and AFTT 1670.33

PROPELLER:   Hartzell PHC-C3YF-1RF/F8068, s/n: EE5585B

The log records a 100 hour inspection on 02/17/16 at 851.3 TSMOH

EQUIPMENT:   Garmin GNS 530, Garmin GTX330, King KY196, King KN53, PS Engineering PMA8000BT, EDM JPI
           
DESCRIPTION OF ACCIDENT:   On 12/12/16, N776WM crash landing in a field

DESCRIPTION OF DAMAGES:    Damage includes but may not be limited to the following:    
                                                              
The aircraft was substantially damaged due to the impact and subsequent fire. 

The engine and tail were completely separated from the fuselage. 

Aircraft sprayed by Fire Dept to extinguish the fire.

LOCATION OF AIRCRAFT:  Florida Air Recovery, Jacksonville, Florida

Read more here:   http://www.avclaims.com


A Beech A36 Bonanza crashed Monday afternoon, causing a small brush fire near Venetian Bay in the New Smyrna Beach area, an official said. 


Emergency crews received the call about 3:30 p.m. regarding a plane crashing and a wing catching fire near Airport Road and Pioneer Trail, Volusia County sheriff's spokesman Andrew Gant said.

The pilot escaped with minor injuries to his face, Gant said.

The Beech A36 Bonanza is owned by Lee and Janet Kraus and registered out of Connecticut, records show. The Krauses own a home in nearby Spruce Creek Fly-In.

Officials have not said who was piloting the plane.

Several residents of Venetian Bay made their way to the intersection of Pioneer Trail and Luna Bella Lane to see what was going on in their neighborhood.

"We were sitting in the house and we saw a big truck go by and then (heard) a big boom," Mary Carrow said.

She said she thought the truck may have blown a tire, and it was unsettling to learn what had actually caused the loud noise.

"We always enjoy them," Carrow said of the planes, "but this is pretty scary."

Story,  video and photo gallery:  http://www.news-journalonline.com






VOLUSIA COUNTY, Fla. — A plane crash was reported Monday afternoon in the area of Airport Road and Pioneer Trail near the Venetian Bay subdivision, according to Volusia County fire officials.

A witness saw the plane go down on the side of the road near a wooded area.

The pilot apparently got out of the plane with just a cut on his nose, WESH 2 News has learned.

The crash started a brush fire that was quickly put out.

An investigation is underway.

Story and video:   http://www.wesh.com

5 comments:

Anonymous said...

Oh the irony ... "Air Conditioned" painted below the offending window.

Nothing like a complicated solution to a situation that required a simple solution.

Glad the injuries were minor .... Ok, severe damage to pride.

7C

CFI no mo' said...

Next time use Duct Tape.

Anonymous said...

He should have used Gorilla tape! Another legacy airplane gone forever due to bad decision making.

Anonymous said...

Glad the pilot is fine.

Beautiful aircraft...G500...tip tanks...turbonormalized. Cruising machine.

Anonymous said...

Reminds me of the urban legend from back in the 1970's when vans were popular and electronics were just beginning to find their place in automobiles. After the crash, the police asked what happened. The young van owner said "I don't know... I put it on "cruise control" and went in the back to get a drink out of the ice box."