Friday, September 8, 2017

North American AT-6 Texan, N3198G, registered to Wings of Flight Foundation: Fatal accident occurred May 17, 2016 near Falcon Field Airport (KFFZ), Mesa, Maricopa County, Arizona

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

NTSB Identification: WPR16FA112
14 CFR Part 91: General Aviation
Accident occurred Tuesday, May 17, 2016 in Mesa, AZ
Probable Cause Approval Date: 09/18/2017
Aircraft: NORTH AMERICAN AT 6, registration: N3198G
Injuries: 2 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.

The airline transport pilot and a passenger departed on a local flight as part of a flight of two airplanes in daytime visual meteorological conditions. Shortly after takeoff, witnesses heard the engine popping; another witness reported a possible loss of power. The airplane entered a right turn and appeared to slow. It subsequently impacted the ground and a postimpact fire ensued. Recorded communication obtained from the air traffic control tower revealed that the pilot transmitted a mayday call before the accident; however, he did not state the nature of the emergency. Postaccident examination of the airframe, flight control system, and the engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. 

The airplane was originally equipped with left- and right-wing fuel tanks, as well as a reserve tank located within the left tank. Maintenance records revealed that the fuel system was modified from its original configuration to remove the reserve tank and interconnect the left and right tanks, therefore allowing for an "On/Off" selection and eliminating the need to switch tanks in flight. The fuel system was again reconfigured; however; no entries in the maintenance records were found regarding this modification. Postaccident examination of the airplane and interviews with the operator revealed that the tank interconnect had been removed, and that the reserve port on the fuel selector valve had been plugged with a blanking cap. The fuel selector valve face displayed four quadrants, one each for the Left, Right, and Off positions, and a blank quadrant where the Reserve position had been previously. Although the Reserve position was not marked, the selector could still be moved to that position, which would result in a loss of fuel flow to the engine. During the wreckage examination, the fuel selector valve was found in a position consistent with the reserve position; however, the fuel selector valve position at the time of the accident could not be determined. 

It is possible that, if the airplane experienced a momentary loss of power, and in accordance with the practice most commonly used by T-6 pilots, the pilot would have selected what was the "reserve" position (although not marked), even though that port was plugged. This would have led to a total loss of engine power due to fuel starvation.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot's inability to return to the departure airport due to an unspecified in-flight emergency for reasons that could not be determined during a postaccident examination of the airplane.

Jesse Goodwin

Ataberk Besler



The National Transportation Safety Board did not travel to the scene of this accident. 

Additional Participating Entity: 
Federal Aviation Administration / Flight Standards District Office; Scottsdale, Arizona 

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

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

N3198G LLC: http://registry.faa.gov/N3198G 

Jesse Goodwin, airline transport pilot


Ataberk Besler, passenger



NTSB Identification: WPR16FA112
14 CFR Part 91: General Aviation
Accident occurred Tuesday, May 17, 2016 in Mesa, AZ
Aircraft: NORTH AMERICAN AT 6, registration: N3198G
Injuries: 2 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 17, 2016, about 1842 mountain standard time, a North American AT-6, N3198G, was destroyed when it impacted terrain shortly after departure from Falcon Field Airport (FFZ), Mesa, Arizona. The airline transport pilot and the passenger were fatally injured. The airplane was registered to Wings of Flight Foundation and operated by the pilot as a 14 Code of Federal Regulations Part 91 air tour flight. Visual meteorological conditions prevailed in the area and no flight plan was filed for the local flight, which originated from FFZ about 1840.

Company personnel reported that the accident airplane was in the trail position behind another company airplane of the same make. The purpose of the flight was to depart FFZ and conduct a tour of the area north of the airport before returning. Witnesses located at the airport saw the airplane depart runway 22L and heard the engine producing "popping" sounds then a loud "bang." One of the witnesses stated that it appeared as though the engine was either not producing any power or not producing enough power. The witnesses further reported that they saw the airplane turning to the right and slowing down. The airplane subsequently impacted the ground and a postcrash fire ensued. 

Review of recorded radio transmissions from the air traffic control tower at FFZ revealed that, about 2 minutes after the flight of two was cleared for takeoff, the accident pilot transmitted "Dash 2 Mayday." The pilot did not state the nature of the emergency. 

PERSONNEL INFORMATION

The pilot, age 43, held an airline transport pilot certificate with airplane single-engine land and multi-engine land ratings. The pilot was issued a first-class Federal Aviation Administration (FAA) medical certificate on July 22, 2015, with no limitations. On the application for that medical certificate, the pilot reported 11,950 total hours of flight experience of which 465 hours were in the previous six months. The pilot's digital logbook, with entries from January 1, 2013, through April 24, 2016, revealed that during that period, the pilot accumulated a total of 2,744.1 flight hours. The pilot had about 50 hours of flight experience in the accident airplane make and model, including about 11 hours in the accident airplane. 

AIRCRAFT INFORMATION

The two-seat, single-engine, low-wing, retractable landing gear airplane, serial number 84-7721, was manufactured in 1942. It was powered by a Pratt & Whitney R1340-AN, 550-hp, reciprocating engine, serial number 2D700, which drove a Hamilton Standard two-bladed, controllable pitch propeller. A review of maintenance records showed that the most recent annual inspection was completed February 13, 2016, at a total aircraft time of 8,746.9 hours.

METEOROLOGICAL CONDITIONS

The nearest automated weather report was from Phoenix-Mesa Gateway Airport (IWA), located 10 miles south of the accident site. The 1859 observation included wind from 290° at 9 knots, 20 statute miles visibility, scattered clouds at 12,000 ft above ground level (agl), ceiling broken at 15,000 ft, temperature 29°C, dew point 4°C, and an altimeter setting of 29.77 inches of mercury (inHg). 

The 1851 observation at Sky Harbor International Airport (PHX), located 14 miles from the accident site, included wind from 310° degrees at 26 knots gusting to 37 knots, 9 miles visibility, scattered clouds at 2,100 ft and 11,000 ft, ceiling broken at 21,000 ft and 25,000 feet, temperature 27°C, dew point 6°C, and an altimeter setting of 29.75 inHg. A peak wind of 320° at 37 knots was recorded at 1844.

The complete weather report is appended to this accident in the public docket.

AIRPORT INFORMATION

FFZ is a tower-controlled airport located at an elevation of 1,394 ft mean sea level (msl). The airport is equipped with two asphalt runways: 4R/22L, which is 5,101 ft long, and 4L/22R, which is 3,799 ft long.



WRECKAGE AND IMPACT INFORMATION

The accident site was located about 1,400 ft from the departure end of runway 22L. The airplane impacted terrain and came to rest on a road on a heading about 37° degrees magnetic. All major structural components of the airplane were located within the wreckage debris path. The wreckage path was oriented on a heading about 12° magnetic and was about 380 ft in length. The first identified point of contact (FIPC) was a 15-ft-tall orange tree. About 20 ft from the tree strike was a section of disturbed ground, about 12 ft in length and 1 ft in width, consistent with a wing strike. The left wing separated from the fuselage and was inverted. The left wing tank, near the inboard separation, was visible and exhibited impact signatures. The remaining debris was contained on the road, with the exception of a separated propeller blade tip. The left aileron and wing tip were separated from the wing and found on the east side of the debris field. About 100 ft to the south-west of the debris field was the separated oil cooler. The oil cooler had impact damage and was surrounded by a pool of oil.

The main wreckage was about 170 ft from the FIPC and consisted of the fuselage, empennage, right wing, and engine. The right wing remained attached to the airplane by one control cable. The right wing came to rest upright on a heading about 120°. The wing was mostly consumed by post impact fire. The fuselage came to rest on its left side on a heading about 310°. The fuselage sustained thermal damage to the lower and left side, revealing the internal structure. The instrument panels for both positions had minor damage. The pilot's seatbelt buckle was secured and thermally damaged; the passenger seat restraint was not located. The engine separated from the airframe and exhibited impact damage to the propeller assembly. The engine mounting structure exhibited impact damage. The oil sump remained attached to the firewall and was leaking oil. The empennage exhibited thermal and impact damage and came to rest on its right side. A fracture-separated propeller blade tip was located about 210 feet from the FIPC. 

The top portion of the forward crew station instrument panel was mostly intact. The bottom portion of the instrument panel, which included all switches, circuit breakers, and radios, exhibited thermal damage. The throttle, mixture, and propeller quadrant was separated with the linkages intact and disconnected from the aft seat controls, consistent with impact. The aft crew station instrument panel exhibited thermal damage and the instruments were charred and unreadable. Both canopies were found in the open position. The fuel selector handle in the forward crew station rotated freely and its position at the time of impact could not be determined. The fuel selector handle in the aft crew station was found detached from the airframe. Both fuel selectors were placarded with "Left", "Right", and "Off" positions. The fuel selector valve was found separated from the center section and subsequently disassembled. The valve was observed in a position consistent with the reserve fuel port, which was capped off with a blanking cap. Both left and right fuel line ports contained melted nylon from the fuel selector valve cone.

Flight control cable continuity was confirmed from each cockpit control to the associated flight control surface through either tension overload separations or cable cuts made during recovery.

All engine accessories remained attached to the engine via their respective mounts, except for the generator and hydraulic pump. The forward spark plugs exhibited normal operational signatures. The propeller was manually rotated and rotational continuity was established throughout the engine to the rear accessory case. Thumb compression and suction was obtained on all cylinders with the exception of the No. 6 cylinder, which exhibited impact damage. The carburetor was disassembled and examined. Both floats remained intact and undamaged. The needle valve was intact. No debris was noted on the fuel screen or in the float bowl. 

The propeller remained attached to the crankshaft flange. Both propeller blades were found secure within the propeller hub. The counterweights were found intact and undamaged. One propeller blade exhibited "S" bending with leading edge gouging and chordwise striations on the forward side of the propeller blade. The opposing propeller blade was curled aft from about mid span, and the outboard tip was separated. The forward side of the propeller blade exhibited chordwise striations. 

The engine driven fuel pump was removed and examined. The fuel pump remained intact and the drive shaft rotated freely by hand. A hand drill was attached to the drive shaft and the fuel inlet line was submerged in water. When the hand drill was actuated, water flowed throughout the fuel pump and was observed expelling from the fuel outlet line. 

Both magnetos were removed for further examination and tested on August 8, 2016 at the facility of Precision Engines LLC., Everett, WA. Bench testing on both magnetos was successful. For further information, see Bendix Magneto Bench Test Report within the public docket for this accident.

No evidence of any preexisting mechanical malfunction was found that would have precluded normal operation of the airframe or engine.

For further information, see the Accident Site Summary Report, and Engine and Airframe Exam Summary Report appended to this accident in the public docket.

MEDICAL AND PATHOLOGICAL INFORMATION

The Maricopa County Office of the Medical Examiner, Phoenix, Arizona, performed an autopsy of the pilot. The cause of death was determined to be "multiple blunt force injuries."

The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicology testing on specimens from the pilot. Specimens tested negative for carbon monoxide in blood and ethanol in urine. No presence of amphetamines, opiates, marijuana, cocaine, phencyclidine, benzodiazepines, barbiturates, antidepressants, or antihistamines was detected in urine.

ADDITIONAL INFORMATION

An entry in the aircraft maintenance records indicated that the airplane was completed by North American Aviation on December 15, 1942, under Type Certificate A-2-575, and shipped directly to the South African Air Force (SAAF). The airplane was originally equipped with left- and right-wing fuel tanks, as well as a reserve tank located within the left tank. The SAAF modified the fuel system as outlined in the supplemental type certificate (STC) SA00636CH (The STC is in the public docket). The modification allowed fuel in the right fuel tank to flow directly to the left fuel tank (from which the reserve fuel tank had been removed) through an interconnecting fuel pipe between the two tanks, and then from the left tank through an "ON/OFF" valve to the engine, thus making fuel tank selection during flight unnecessary. 

No maintenance records were recovered for the period between 1989 and 1995. In 1996, the airplane returned to and was registered in the United States. On April 11, 1997, the airplane was issued a Special Airworthiness Certificate in the experimental category. On May 3, 1997, a Standard Airworthiness Certificate was issued, which indicated that the airplane conformed to Type Certificate Data Sheet (TCDS) A-2-575 Revision 13. However, a postaccident review of the TCDS indicated that, based on its S/N, the accident airplane was not eligible for a standard type certification. 

The airplane's fuel system was reconfigured at an unknown time and no entries in the maintenance records were found regarding the fuel system modification. The postaccident examination of the fuel system indicated that the interconnecting fuel pipe between the left and right tanks had been removed and that the reserve port on the fuel selector valve was capped. The left fuel tank reserve port stand pipe was also removed. The fuel selector valve face displayed four quadrants, one each for the Left, Right, and Off positions, and a blank quadrant where the Reserve position had previously been located. Although the Reserve position was not marked, the selector could still be moved to that position and would result in a loss of fuel flow to the engine since that port had been capped. During the wreckage examination, the fuel selector valve was found in a position consistent with the Reserve position; however, the position of the valve at the time of the accident could not be determined.

In an interview with an FAA inspector, the operator stated that the fuel selector was made of cork and that excessive manipulation of it could lead to damage or internal wear. The fuel selector was rarely moved and normally stayed on the left tank position, as most flights were short and did not necessitate the use of both fuel tanks. The selector would only be moved during flights of extended duration or if the pilot perceived a fuel-related issue. The operator indicated that the last time the airplane flew before the day of the accident was on the weekend of April 12, 2016 from FFZ to Phoenix-Mesa Gateway Airport (IWA), Mesa, Arizona, and back, which was about 20-minute flight each way. The airplane was topped off at IWA. The operator stated that the accident flight was the second flight of the day; the first flight lasted about 30 minutes or less. The FAA inspector estimated that the airplane would have flown about 50 minutes to an hour since it was refueled on the left fuel tank. When the FAA inspector queried the operator regarding their leaning procedures, they stated that on most of their flights, which were 20-30 minutes in length around the area, they would lean very little if at all. However, they would lean on the rare longer cross-country flights or if it was at a high-altitude airport.

The FAA inspector also interviewed a few T-6 pilots, and the common practice amongst them was that, in case of a fuel interruption, a pilot should select a "reserve" position for those airplanes that were equipped with the reserve position.










NTSB Identification: WPR16FA112
14 CFR Part 91: General Aviation
Accident occurred Tuesday, May 17, 2016 in Mesa, AZ
Aircraft: NORTH AMERICAN AT 6, registration: N3198G
Injuries: 2 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 May 17, 2016, about 1842 mountain standard time, a North American AT-6, N3198G, was destroyed when it impacted terrain shortly after departure from Falcon Field Airport (FFZ), Mesa, Arizona. The pilot and the passenger were fatally injured. The airplane was registered to Wings of Flight Foundation, and operated by the pilot as a 14 Code of Federal Regulations (CFR) Part 91 air tour flight. Visual meteorological conditions prevailed for the flight, and no flight plan had been filed. The local flight originated from FFZ at 1841 mountain standard time.

Multiple witnesses reported that shortly after takeoff they heard "popping" sounds accompanied with a loud "bang" and it appeared that the engine was not producing enough power. As the airplane exited the airport boundary, above an airport perimeter road, it made an 180-degree turn. Immediately thereafter, the airplane impacted the ground and a postimpact fire ensued. 

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