Sunday, February 05, 2017

Loss of Control in Flight: Pitts S-2B Special, N877UP; fatal accident occurred June 27, 2015 at Cameron Memorial Airport (KEZZ), Cameron, Missouri

Steven Carl O'Berg
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Aviation Accident Final Report - National Transportation Safety Board

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Kansas City, Missouri
Lycoming Engines; Williamsport, Pennsylvania 
The NTSB traveled to the scene of this accident.

Investigation Docket - National Transportation Safety Board:
 
O'Berg Aviation Service LLC


Location: Cameron, Missouri
Accident Number: CEN15FA282
Date & Time: June 27, 2015, 13:53 Local 
Registration: N877UP
Aircraft: CHRISTEN INDUSTRIES INC PITTS S2B
Aircraft Damage: Substantial
Defining Event: Loss of control in flight 
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General aviation - Air race/show

Analysis

The pilot was performing a series of aerobatic flight maneuvers at a low altitude during an airshow. Another airshow pilot, who was familiar with the accident pilot's airshow routine, reported that the accident pilot intended to do a 45-degree knife-edge climb, perform a "Lomcevak" maneuver, and then continue the knife-edge climb. Video recordings taken by persons on the ground showed the airplane in a knife-edge climb. The pilot then entered the Lomcevak maneuver by performing a climbing snap-roll to the left. The airplane pitched nose-down and tumbled two times to the left while descending. Rather than returning to the knife-edge climb, the airplane instead entered a left spin and completed about two and a half revolutions before it impacted the terrain. The video recordings indicated that the engine was operating throughout the flight to ground impact.

A postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. A review of medical, pathological, and toxicological information revealed no evidence of any medical condition or substance that would have contributed to the pilot's loss of control during performance of aerobatic maneuvers.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's failure to maintain airplane control during a low-level aerobatic flight maneuver.

Findings

Personnel issues Aircraft control - Pilot
Aircraft Angle of attack - Not attained/maintained

Factual Information

History of Flight

Maneuvering-aerobatics Loss of control in flight (Defining event)
Maneuvering-aerobatics Aerodynamic stall/spin
Uncontrolled descent Collision with terr/obj (non-CFIT)

On June 27, 2015, about 1353 central daylight time, a Christen Industries Pitts S-2B, N877UP, sustained substantial damage when it impacted terrain during an aerobatic flight at the Cameron Memorial Airport (EZZ), Cameron, Missouri. The airline transport pilot received fatal injuries. The airplane was registered to and operated by the pilot under the provisions of the 14 Code of Federal Regulations as a Part 91 airshow flight. Day visual meteorological conditions prevailed for the airshow demonstration flight that departed from EZZ about 1340. No flight plan was filed. 

The pilot's flight demonstration card used during the airshow indicated that he planned to do 10 aerobatic maneuvers during the flight. For the ninth maneuver, it indicated that he planned to do a Lomcevak maneuver, an advanced aerobatic maneuver. An airshow pilot who was familiar with the accident pilot's airshow routine, reported that the accident pilot intended to do a 45-degree knife-edge climb, perform the Lomcevak maneuver, and then continue the knife-edge climb. 

Video recordings taken by persons on the ground showed the airplane flying the planned routines. The eighth aerobatic maneuver was a steep climb maneuver to a near stalled condition that the pilot titled a "chopper (helicopter) pass." After the chopper pass, the airplane entered a dive to gain airspeed. It then flew straight and level for about 5 seconds before doing a course reversal by pulling up into a left climb and then turning back to the right before diving down to gain airspeed. Then it pulled up and flew straight and level for about 4 seconds before entering into about a 30-degree knife-edge climb. During the knife-edge climb, the airplane appeared to enter the Lomcevak maneuver by doing a climbing snap-roll to the left. The nose of the airplane pitched down and the airplane tumbled two times to the left while descending. The airplane entered a left spin and completed about two and a half revolutions before it impacted the terrain.

PILOT INFORMATION

Certificate: Airline transport 
Age: 50,Male
Airplane Rating(s): Single-engine land; Multi-engine land
Seat Occupied: Single
Other Aircraft Rating(s): Helicopter
Restraint Used: 5-point
Instrument Rating(s): Airplane; Helicopter 
Second Pilot Present: No
Instructor Rating(s): Airplane multi-engine; Helicopter; Instrument airplane; Instrument helicopter
Toxicology Performed: Yes
Medical Certification: Class 1 With waivers/limitations
Last FAA Medical Exam: February 15, 2015
Occupational Pilot: Yes
Last Flight Review or Equivalent:
Flight Time: 11000 hours (Total, all aircraft), 200 hours (Total, this make and model)

The 50-year-old pilot held an airline transport pilot certificate with single-engine land, multi-engine land, helicopter, airplane instrument, and helicopter instrument ratings. He was also an instructor pilot with airplane single-engine, multi-engine, helicopter, airplane instrument, and helicopter instrument instructor ratings. He held a first class medical certificate issued in February 15, 2015. The pilot completed an insurance application on August 25, 2014, that indicated that he had a total of 11,000 flight hours with 200 hours in the accident airplane make and model. The pilot held a Level 3 Statement of Aerobatic Competency from the Federal Aviation Administration for solo aerobatics with a 500 ft base altitude limit in Pitts airplanes. The Level 3 flight evaluation was conducted on May 7, 2015. 

AIRCRAFT INFORMATION

The airplane was a Christen Industries factory-built, tandem two-seat, experimental single-engine Pitts S-2B biplane manufactured in 1985. It was equipped with a 300-horsepower aerobatic Lycoming AEIO-540-D4A5 engine, serial number L-22892-48A. The engine powered a 3-bladed MT propeller. The most recent annual maintenance inspection was conducted on May 1, 2015, with a total aircraft time on 1,806 hours. The airplane had 1,819 total hours at the time of the accident. The engine had a total time of 141.2 hours since the last overhaul. 

METEOROLOGICAL INFORMATION

At 1353, the surface weather observation at Kansas City International Airport (MCI), located 33 nm northwest of EZZ, was: wind variable at 5 kts; visibility 10 miles; sky condition scattered clouds at 4,500 ft; temperature 26 degrees C; dew point 16 degrees C; altimeter 30.10 inches of mercury. 

WRECKAGE AND IMPACT INFORMATION

The airplane impacted the trees and terrain in a shallow nose down attitude with a high vertical descent rate. The engine compartment, fuselage, wings, and empennage exhibited crushing and buckling from the ground impact, but the airplane remained intact. There was no post impact ground fire. The engine compartment exhibited upward crushing, and the leading edges of the wings did not exhibit aft crushing. Flight control continuity was confirmed from all flight control surfaces to their respective cockpit controls. The elevator trim continuity was confirmed from the elevator trim tabs to the elevator trim control. 

The engine was shipped to the manufacturer for examination. The examination revealed that the damage to the engine would not preclude an engine run on a test stand. Due to impact damage, the following slaved parts were used during the engine run test: fuel servo, magneto harness, 2 spark plugs, 3 intake pipes, oil supply hoses, fuel supply hoses, oil filter base, fuel pump, and starter support. The engine was installed in an engine test cell for an engine run. The engine was started and operated at the following points: 1) warm up at 1,500 rpm for 5 minutes; 2) run at 1,800 rpm for 5 minutes; 3) run at 2,200 rpm for 5 minutes; 4) magneto check at 2,200 rpm; 5) rated run at 2,700 rpm for 10 minutes; 6) idle run for 5 minutes; and 7) manual acceleration check. The engine passed all points within the prescribed limits of the engine run. 

The fuel pump was examined. It displayed significant damage, including several cracks in the body, and separation at the screw-fastened interface between two of the subcomponents, and with two of the screws no longer in their installed position, and others loose. The screws and their mating, threaded holes were examined. None of the screws were broken, but all of them had metallic material present in their lower threads, along with some hardened, blue colored nonmetallic substance consistent with a cured thread locking compound. The mating, internal threads in the pump body were severely stripped. 

MEDICAL AND PATHOLOGICAL INFORMATION

The autopsy of the pilot was performed at the Frontier Forensics Morgue, Kansas City, Missouri, on June 28, 2015. The cause of death was from multiple blunt force injuries sustained in an airplane accident. A Forensic Toxicology Fatal Accident Report was prepared by the FAA Civil Aerospace Medical Institute. No carbon monoxide was detected in the blood (cavity). No ethanol was detected in the vitreous. Azacyclonol was detected in the urine but not detected in the blood (femoral). Fexofenadine was detected in the urine and the blood (femoral). Ibuprofen was detected in the urine. 

Fexofenadine is a non-sedating antihistamine available over the counter; it is commonly marketed with the name Allegra. Ibuprofen is a non-steroidal anti-inflammatory medication available over the counter with the names Motrin and Advil. 

TESTS AND RESEARCH

The National Transportation Safety Board's (NTSB) Vehicle Recorder Division received three image files containing video and audio that captured the accident. The recorder laboratory correlated the videos to local time and a summary of the flight was made. In brief, the video files showed the aircraft performing aerobatic maneuvers while producing a smoke oil trail throughout the flight.

At 1351:56, the aircraft was straight and leveled as it prepared for its next maneuver two seconds later.

At 1351:58, the aircraft began to climb. The smoke oil trail indicated a constant angle climb. Two seconds later the aircraft rolled left wing down as it continued its constant angle climb.

At 1352:02, the aircraft performed a 360 degree rolling maneuver which resulted in the aircraft tumbling toward the ground. The tumble was similar to an aerobatic maneuver known as the "Lomcevak". At this time, the sound of the engine became faint and the trailing smoke oil began to dissipate.

At 1352:11, the aircraft continued tumbling and smoke oil trails became visible again when the sound of the engine became noticeable again. The sound of the engine and smoke oil trails remained noticeable until impact.

At 1352:12, the aircraft ended its tumble but continued nose down descending toward the ground.

At 1352:13, the sound of the engine ends as the aircraft impacted the ground.

ADDITIONAL INFORMATION

The Lomcevak is a family of aerobatic flight maneuvers where the aircraft, with almost no forward airspeed, rotates on chosen axes due to gyroscopic precession and torque of the rotating propeller. One type of Lomcevak is an when the pilot follows a knife-edge roll by flipping the airplane end-over-end and into a spin, from which the pilot then recovers control of the airplane.

NTSB Identification: CEN15FA282

14 CFR Part 91: General Aviation
Accident occurred Saturday, June 27, 2015 in Cameron, MO
Aircraft: CHRISTEN INDUSTRIES INC PITTS S-2B, registration: N877UP
Injuries: 1 Fatal.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. 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.


On June 27, 2015, about 1353 central daylight time, a Christen Industries Pitts S-2B, N877UP, sustained substantial damage when it impacted terrain during an aerobatic flight over the Cameron Memorial Airport (EZZ), Cameron, Missouri. The airline transport pilot received fatal injuries. The airplane was registered to and operated by the pilot under the provisions of the 14 Code of Federal Regulations as a Part 91 airshow flight. Day visual meteorological conditions prevailed for the airshow demonstration flight that departed from EZZ about 1330. No flight plan was filed.


The pilot's flight demonstration card used during the airshow indicated that the pilot planned to do 10 aerobatic maneuvers during the flight. For the ninth maneuver, it indicated that he planned to do a Lomcevak maneuver. An airshow pilot who was familiar with the accident pilot's airshow routine, reported that the accident pilot intended to do a 45-degree knife-edge climb, perform the Lomcevak maneuver, and then continue the knife-edge climb. Video recordings taken by persons on the ground showed the airplane flying through the planned routines. Between the eighth and ninth aerobatic maneuvers, the videos showed the airplane doing a course reversal, and then flying straight and level before entering into a knife-edge climb. During the knife-edge climb, the airplane appeared to enter the Lomcevak maneuver by doing a climbing snap-roll to the left. Then the nose of the airplane pitched down and the airplane tumbled two times to the left while descending. The airplane appeared to enter a left spin and completed about two and a half revolutions before it impacted the terrain.


The airplane impacted the trees and terrain in a shallow nose down attitude with a high vertical descent rate. The engine compartment, fuselage, wings, and empennage remained intact and there was no post impact ground fire. The engine compartment exhibited upward crushing, and the leading edges of the wings did not exhibit aft crushing. Flight control continuity was confirmed from all flight control surfaces to their respective cockpit controls. The elevator trim continuity was confirmed from the elevator trim tabs to the elevator trim control.


The engine will be shipped to the manufacturer for an engine teardown examination. The videos and still photographs of the accident flight will be examined at the National Transportation Safety Board's (NTSB) Vehicle Recorder laboratory.

Steve O’Berg
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Steven Carl O'Berg, 50 of Smithville, MO died Saturday, June 27, 2015 while piloting his beloved Pitts S2-B aerobatic plane at the Cameron Air Show. Visitation is from 5 to 7 p.m. Tuesday, July 7, 2015 at Bruce Funeral Home 106 S Center, Gardner, KS. Memorial services will be 10:00 Wednesday, July 8 at Paradise Pointe Golf Complex, 18212 Golf Course Road, Smithville, MO. In lieu of flowers the family suggests memorial donations to the Aircraft Owners & Pilots Association (AOPA.org) or the Experimental Aircraft Association (EAA.org) KS. 

Steve was born May 29, 1965 to Fremont "Dusty" and Marlene (Silver) O'Berg in Oklahoma City, OK. He graduated from Gardner- Edgerton (KS) High School in 1983. On February 4, 2010 he married Karri Williams of Topeka, KS. He retired from a 23 year military career in 2007. Since his military retirement, he flew in a variety of private aviation roles. Steve flew both rotor and fixed wing aircraft over his career span. He accumulated over 5000 military flight hours including over 400 combat hours in Iraq. His private flight hours totaled over 7000 hours. 

Steve approached everything in life full bore and with passion. This included his love for his family, anything aviation and his hobbies. If it included an adrenaline rush it was likely a hobby of Steve's. Motorcycles, snowmobiles, boats, skiing, wakeboarding, skydiving, anything fast! The only things he did slow were eat and arrive at family functions. His quick wit, sense of humor and ability to see the sunny side of everything will be so missed by his family and friends. He spent his life doing for others. 

He was preceded in death by his grandparents, Fremont "Red" Sr. and Edna O'Berg, Horace and DeLamar Silver and father Fremont "Dusty" O'Berg. He is survived by his wife Karri (Williams) and two children Stephanie Rainbolt (Rusty) and Brody O'Berg, 2 stepdaughters, Danielle Sumpter (Brent) and Whitney Peavler and two grandchildren, Evie and Wyatt Rainbolt. Mother, Marlene O'Berg, sister, Vickie Couch (Michael), sister, Marilyn Davidson (David), brother, David O'Berg and sister, Julie Harper (Donny) and many nieces, nephews and cousins and countless extended friends and family spread across the globe. 

18 comments:

  1. I honestly can’t believe that anyone watching this air show can conclude that this was pilot error. Viewing this routine as a mechanic I can clearly hear the engine partially stall or miss at least twice early in the routine it’s my belief that when the pilot demanded power at the critical moment to recover from this manoeuvre it wasn’t there when it finally regained power it was too late I think it is unfair to say this is the pilots fault if anything I think he should have landed the first or second time it cut out on him
    Regards Mike

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    1. Like you, I believe there was a lack of power from the engine to complete the maneuver. Sounds like in the last moments he's struggling to get the power back.
      Just my non expert opinion.

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    2. From watching video, you are absolutely right. Maybe a fuel pressure issue?

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    3. Totally agree with you guys who say it sounds like the engine failed to give him full power - twice in a row for whatever reason - when he needed it!

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    4. agreed. The motor never came back up, seemed to miss.

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    5. I completely agree... And, the people who are saying the microphone doesn't cover the sound correctly are full of Sheot. Even with a slight delay in sound, you can clearly hear the engine struggling at times = not coming back to full power, as it earlier in his routine. It's all too easy to blame it on "pilot error"... This is like a scuba diving death.. Almost always blamed on drowning. Rarely do you hear that what precipitated it was a gear failure.

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  2. When considering engine sounds present on the video, it's important to remember the distance between camera/microphone and the aircraft. The engine could be at significantly higher RPM than the sound observed, depending on the time required for sounds to reach the microphone. I read about a 500 min agl limit for aerobatic maneuvers but don't know whether this limit would have applied to this demonstration. It seemed to me that the aircraft was in a very low energy state at a low altitude. This could lead to a situation that would not allow continued flight, regardless of engine performance. I'm not an aerobatic pilot but I know various throttle positions are sometimes used in recovery. I think a mechanical failure could be a possibility but airplanes don't fly primarily because of engine power; they fly because of wing lift.

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  3. I see the control column had fractured at the base. After many hours of aerobatic flying, a series of S2A Pitts had to have the base of the control column reinforced with a saddle type reinforcement as cracks had been detected in that area. I wonder.....

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  4. Great pilot ! But he was too low for recover and no air speed.

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  5. Up to a minute before his crash,I noticed that his smoke trail was intermittently streaked with black smoke.i have only seen this with mechanical issues.it seems to me that he could have been
    Made aware before his crash. I don't see pilot error here, only that the pilot may have been lower than he should have for reaction and recovery of a troubled plane.if the dirty smoke trail is common, please reply id like to know. Thanks, John

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  6. It seems he was flying too low to complete that maneuver.

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  7. The thing about airshow aerobatics is that you are nearly always always too low to recover from a mistake, that's why mistakes at low altitude are usually fatal. Looks like the plane entered an unintentional spin and he didn't have the height to recover in time. During a spin the engine is throttled back to idle otherwise you just get to the ground twice as fast and it inhibits recovery. PARE. Power idle, ailerons neutral, rudder opposite to spin, then elevator forward to fly out once the spin is broken.
    This takes time and height (which he didn't have) you lose about 340 ft per turn and it takes about 1 - 1.5 turns to break the spin, then another 300 - 500 ft to recover to level flight.
    Its very unfortunate but at air show height if you get into an unplanned figure such as a spin, the results are usually fatal.

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    1. 100%. It wasn’t an engine fault. It was an unintentional spin and not enough altitude to recover.

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  8. I totally agree with the first unknown commenter!!! You can CLEARLY hear Steve trying to get the power back TWICE and for some reason the engine didn't give it to him! It was NOT pilot error! And to the commenter who was talking about the mic and speed of sound travel and how it could have affected what you heard, sorry it is very clear that he tried twice to apply power to recover but it just wasn't there for what ever reason.

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    1. Actually, it sounds like he tried 3 times to regain power but each time the engine wouldn't give him the power to climb back out. If you listen carefully, as he is coming out of the maneuver to level out, it sounds like he tries to apply power (by the engine revving up and dropping back off) 3 times before crashing. It sounds very clear from the engine sound that he tried to regain power but each time the engine dropped off and failed to give him power.

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    2. I think comments about engine power are from non aerobatic pilots: power for the Lomcevak maneuver is kept in - and you can hear in the video that there were no power issues during the tumbling - the maneuver resulted in an unintentional spin, and as stated before, power is pulled out. I think the subsequent sounds of putting power in and out were desperate attempts to do anything to rectify a doomed situation. Power is not used in spin recovery - and here power was attempted multiple times to see if it helped - but given the altitude there really wasn't anything to be done from a fully developed spin. This accident had nothing to do with power or lack thereof

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  9. Kjenner bare til spinn med Sab Safir som jeg var mekaniker på. Ser ut for meg som et merkelig spinn, og at S var ute av det. Med full gass og 300hk burde noe reagert.- Jeg ville vel febrilsk ha gjort det når bakken kom til syne. Men det er visst ikke slik det skal gjøres. Trenger en Pitts kanskje 6 sek for å lette,? Det hadde jo noe fart ut av spinnet, så hvorfor? Og Mesterpiloten med 11000 timer i lufta da?!

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  10. Jack poage who ran my home town airport in westminster md was killed in his pitts2 plane just like this one at Martin state airport airshow years ago.shame that thee great pilots had mishaps that took them.i miss watching him practice evenings while at airport .I went on to buy a plane and love flying just like jack.

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