Sunday, April 16, 2017

Cessna 172G Skyhawk, N3969L: Fatal accident occurred May 03, 2015 at Penn Yan Airport (KPEO), Yates County, New York

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

NTSB Identification: ERA15FA203
14 CFR Part 91: General Aviation
Accident occurred Sunday, May 03, 2015 in Penn Yan, NY
Probable Cause Approval Date: 04/20/2017
Aircraft: CESSNA 172, registration: N3969L
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.

On the morning of the accident, the student pilot departed from his home airport and flew to two other airports before returning to his home airport. None of these cross-country flights were conducted under the supervision of a flight instructor nor was there any documentation available to show that the student was endorsed to conduct these flights. Upon reaching his home airport, the student pilot entered the traffic pattern to land on the 5,500-ft-long runway with a prevailing right quartering tailwind. A pilot-rated witness reported that he saw the airplane approach the runway "high and fast," that it was about 100 to 150 ft above the ground as it crossed over the runway threshold, and that it then appeared to "float" down the runway. He then lost sight of the airplane. Another witness noted that, after touching down near the midpoint of the runway, the airplane lifted off and reached about 50 ft above the ground, at which point, the engine power increased. The airplane then began climbing steeply and then banked left, making an arcing flightpath that continued to ground contact. Based on available evidence, the investigation was unable to determine whether the pilot was attempting to conduct a go-around following the previous landing approach, or was conducting a touch-and-go landing when the accident occurred.

Postaccident examination of the airframe and engine revealed no evidence of any mechanical malfunctions or failures that would have precluded normal operation. Although fuel drained from the airplane after the accident contained water, witness statements and wreckage signatures were consistent with the engine operating normally to ground impact. The flaps were found extended 40°; however, airplane manufacturer guidance stated that during a go-around climb, the "flap setting should be reduced to 20° immediately after full power is applied" and that "flap settings of 30° to 40° are not recommended at any time for takeoff." It is likely that the inappropriate flap setting for the initial climb contributed to the student pilot's failure to maintain airplane control.

Although the student pilot's autopsy identified the presence of coronary artery disease that could have caused acute symptoms such as chest pain, shortness of breath, palpitations, or fainting, there was no evidence of any such event occurring.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The student pilot's failure to maintain airplane control during the initial climb. Contributing to the accident was the student's inappropriate configuration of the airplane's wing flaps for the initial climb.


Steven P. Seely


The National Transportation Safety Board traveled to the scene of this accident. 

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Rochester, New York 
Textron Aviation; Wichita, Kansas 

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

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

Steven P. Seely: http://registry.faa.gov/N3969L




NTSB Identification: ERA15FA203
14 CFR Part 91: General Aviation
Accident occurred Sunday, May 03, 2015 in Penn Yan, NY
Aircraft: CESSNA 172, registration: N3969L
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.

HISTORY OF FLIGHT

On May 3, 2015, at 1134 eastern daylight time, a Cessna 172G, N3969L, impacted terrain and an airport perimeter fence during initial climb at Penn Yan Airport (PEO), Penn Yan, New York. The airplane was being operated as a 14 Code of Federal Regulations Part 91 personal flight. The student pilot was fatally injured, and the airplane sustained substantial damage. Visual meteorological conditions prevailed at PEO about the time of the accident, and no flight plan was filed. The flight originated from Finger Lakes Regional Airport (0G7), Seneca Falls, New York, about 1115.

On the morning of the accident, the pilot contacted flight service and requested a weather briefing for a flight from PEO to Oswego County Airport (FZY), Fulton, New York, departing about 0730 and returning about 1100. The briefer advised the pilot of the current conditions at PEO and FZY, the forecast sky conditions for the area, and the NOTAMs applicable for the proposed flight.

Review of airport security video footage showed that the accident airplane began taxiing at PEO about 0800. Data downloaded from a handheld GPS receiver recovered from the accident site showed that the device began recording on the morning of the accident at 0818. The airplane's first recorded position was about 22 nautical miles (nm) northeast of PEO, roughly along a course line between PEO and FZY. Over the next 17 minutes, three additional positions were recorded, the last of which was at 0835 and showed the airplane about 3 nm south of FZY. The next position was recorded at 0944 and showed the airplane about 2 nm southwest of FZY. Over the next 17 minutes, three additional positions were recorded; the last recorded position showed the airplane about 5 nm northeast of 0G7.

The airplane arrived at 0G7 on the morning of the accident, and the student pilot spoke with his mechanic. According to the mechanic, he and the pilot discussed an ongoing issue with the airplane involving water contamination of its fuel. The pilot and mechanic then drained about 1 quart of fuel through the fuel strainer before it was clear of water. At the pilot's request, the mechanic inspected the airplane's right main landing gear, relubricated the wheel bearings, and reinstalled the wheel and tire. The mechanic noted no discrepancies with the landing gear, wheel, or brakes during his inspection. The mechanic stated that the pilot departed 0G7 about 1100 and planned to return to PEO. After departure, three GPS positions were recorded starting at 1117; the first recorded position showed the airplane about 1.5 nm southwest of 0G7, and the final position, which was recorded at 1129, showed the airplane about 2 nm southeast of PEO.

Airport security video footage from PEO showed a high-wing airplane on approach to runway 19 at 1131. During a second approach to the runway at 1134, the airplane crossed the runway threshold at a significantly higher altitude than during the first approach. Review of the videos could not determine whether the airplane touched down during either of the approaches, based on the viewing angle of the camera.

A pilot-rated witness observed the accident airplane in the traffic pattern for runway 19 before the accident. Regarding the second approach, he stated that, as the airplane turned left from 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 wind to be from about 320° and "greater than 10 knots." He stated that, while on final approach, the airplane appeared to be "high and fast." He estimated it was about 100 to 150 ft 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. He realized that the airplane had crashed when he saw first responders arriving at the airport several minutes later. 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 was at idle speed.

Another witness was located on a golf course adjacent to the airport near the midpoint 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 added that the engine sounded "normal," and the climb appeared normal from the time the airplane lifted off until it reached about 50 ft. At that point, the airplane began climbing at a faster rate than it had been previously and then banked left. The airplane also appeared to be higher and climbing faster than other airplanes he had previously observed about the same location. He added that the airplane then descended while continuing the left banking arc, as if the left wing was "tied to the ground with a string."

PERSONNEL INFORMATION

The pilot held a student pilot certificate and Federal Aviation Administration (FAA) third-class medical certificate, which was issued on January 20, 2014. The medical certificate was issued with the limitation, "Must wear corrective lenses." The pilot's flight logs were not recovered.

According to the pilot's flight instructor, the pilot had completed some initial flight instruction in an airplane that belonged to a local flying club. The pilot began flight training with the flight instructor about 1 year before the accident, and all of their flights were in the accident airplane. The flight instructor endorsed the pilot for solo flight around October 2014. After completing additional dual instructional and solo flights, the pilot took a hiatus from flying during the winter, and they began their training again in March 2015. At that time, the flight instructor provided the pilot with an additional 90-day solo endorsement. The flight instructor had not yet provided the pilot with an endorsement to fly to airports other than PEO and was not previously aware that the pilot had flown his airplane solo to FZY and 0G7 on the morning of the accident. The flight instructor estimated that the pilot had accumulated 40 total hours of flight experience.

The flight instructor reported that the pilot generally performed well landing the airplane but that landings were his weakest area. During their training, they practiced performing go-arounds from a full-flap configuration, and the pilot excelled at it. The flight instructor also thought it was important to fly with the pilot in strong crosswinds, and as such, the additional challenge of these conditions delayed his initial solo. By the time the pilot did solo, the flight instructor had confidence in his ability to handle crosswinds, and, recently, his landings had greatly improved. Their last flight together was on April 29, and it was a cross-country flight to Zelienople, Pennsylvania. The flight instructor stated that, during all of his flights in the accident airplane, he did not note any mechanical discrepancies.

AIRCRAFT INFORMATION

According to FAA registration records, the pilot purchased the accident airplane in May 2014. A review of maintenance logbooks revealed that new main and nose landing gear tires were installed on May 15, 2014, at an airframe total time of 4,558 flight hours. The airplane's most recent annual inspection was completed on August 17, 2014, at an airframe total time of 4,575 flight hours and 784 hours since the engine's most recent overhaul. An airframe maintenance log entry made the day of the accident noted that the right main landing gear wheel bearing and brake pads were installed, and that the wheel bearing was regreased and then reinstalled. At the time of the accident, the airframe had accumulated 4,625 total flight hours.

METEOROLOGICAL INFORMATION

The 1135 weather observation at PEO included wind from 310° at 8 knots, 10 statute miles visibility, clear skies, temperature 73° F, dew point 37° F, and an altimeter setting of 30.08 inches of mercury.

AIRPORT INFORMATION

Runway 19 at PEO was 5,499 ft long and 100 ft wide. The approach end of the runway had an elevation of 916 ft, and the departure end of the runway had an elevation of 987 ft, or a 1.4% gradient. A two-light precision approach path indicator was available at both runway ends.




WRECKAGE AND IMPACT INFORMATION

The airplane came to rest upright with the right wing resting on the airport perimeter fence, about 300 ft left of the runway centerline and about 2,800 ft 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 magnetic heading of 145°. A piece of left wing navigation light was located in the wreckage path about 20 ft from the initial impact point. About 15 ft further down the path, a ground scar was found oriented 90° to the path, about the length of the propeller diameter and the width of a propeller blade. About 2 ft further down the path was an impact crater that was 3 ft wide and 8 ft long and contained paint chips and windscreen fragments, followed by the main wreckage, which came to rest oriented on a magnetic heading of about 340°.

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 of the 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 near the vent tube and that they subsequently drained about 7 gallons of fuel from the left wing and about 10 gallons of fuel from the right wing. Fuel samples from both tanks displayed a color and odor consistent with automotive gasoline. 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° to 10° of tab deflection in the nose-up direction. The flap actuator extension was measured and found in a position consistent with a 40° 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 was confirmed from the valve and powertrains to the rear accessory gears. The oil screen and paper oil filter element were unobstructed and free of metallic contamination. The spark plugs were removed, and the No. 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 free of debris. The carburetor floats were intact, and both displayed concave, inward, uniform deformation. The magnetos were removed and actuated by hand, and spark was observed at each of their respective terminal leads.

MEDICAL AND PATHOLOGICAL INFORMATION

The Geneva General Hospital Laboratory, Geneva, New York, performed an autopsy of the pilot. The reported cause of death was "crash related injuries." The autopsy report also identified significant coronary artery disease with a heart weight of 510 grams. The right ventricle was 0.5 centimeter (cm) thick, and the left ventricle was 1.5 cm thick. In addition, all three main coronary arteries were narrowed at least 50% and up to 75% by atherosclerosis, but there were no areas of scarring from previous heart attacks. The liver and stomach were also mildly inflamed.

The FAA's Civil Aerospace Medical Institute performed toxicological testing on specimens from the pilot. The results were negative for ethanol, carbon monoxide, and drugs.

ADDITIONAL INFORMATION

According to the 1966 Cessna Model 172 and Skyhawk Owner's Manual, "Slips are prohibited in full flap approaches because of a downward pitch encountered under certain conditions of airspeed and sideslip angle." Additionally, the manual stated that "In a balked landing (go-around) climb, the wing flap setting should be reduced to 20° immediately after full power is applied," and that "Flap settings of 30° to 40° are not recommended at any time for takeoff."

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