Sunday, May 14, 2017
Pilots, leaders up in air over plane tax hike proposal: Danville Regional Airport (KDAN), Virginia
Danville City Council will decide whether to more than double the city’s airplane tax during its meeting Tuesday night.
Raising the tax on aircraft from 30 cents per $100 of assessed value to as high as 70 cents is on the table, along with other proposed tax increases including those for real estate, personal property, meals and lodging.
Mayor John Gilstrap opposes raising the rate far out of proportion to the increase proposed for personal property — which could go from $3 to $3.50 per $100 of assessed value.
“I would support not increasing it at all, but I could support a small increase not to exceed 40 cents,” Gilstrap said, adding that he will not support the 70-cent proposal.
Danville Transportation Director Marc Adelman said he was asked by city officials to research airplane tax rates in other localities and to provide a recommendation to the Danville Regional Airport Commission. Adelman recommended a rate not to exceed 70 cents in order to remain competitive with small airports in North Carolina.
Danville Regional Airport has about 40-42 aircraft, including seven from Averett University — which is exempt from the tax, Adelman said. There are about 35 taxable aircraft at the airport in a given year, Adelman said.
More than 40 percent of the aircraft there are owned by people from outside Virginia, and more than 20 percent of owners are from North Carolina, Adelman said.
“We have to be competitive with North Carolina airports because their [North Carolina’s] aircraft owners are traveling to base their airplanes here,” Adelman said.
City Councilman Fred Shanks initially proposed raising the rate to 90 cents during a work session to find other sources of revenue to offset a proposed increase in the real estate tax rate.
When contacted by the Danville Register & Bee on Sunday, Shanks said he was not trying to raise the rate to 90 cents, but was try to bring it up to par with other localities. Also, he sought guidance from staff to find a reasonable rate, he said.
Shanks said he is not in favor of tax increases, but if the city is going to raise taxes on real estate, personal property, meals and lodging, then the rate charged for airplanes should be in line with other localities.
The current 30-cent rate on airplanes is unfair when the personal property tax rates for vehicles would be $3.50 per $100 of assessed value — the rate proposed for 2017-18, Shanks said.
“If you own a $25,000 pickup truck, you’re going to pay $3.50,” Shanks said. “But the guy with a $25,000 airplane is only paying 30 cents. That’s just way out of whack.”
At least two pilots who store their planes at Danville Regional Airport oppose the tax increase on aircraft.
John D. Smith III, a Rockingham County, North Carolina, resident who has kept his Cessna Citation jet at the airport for eight years, said he would move his aircraft to Rockingham County if the tax were to increase to 90 cents and his hangar rent were to go up.
“I sincerely hope that the Danville City Council will reconsider the proposed price increases before finalizing them,” Smith wrote in a letter to Danville City Councilman Lee Vogler.
Smith pays $8,580 per year for hangar rent and $3,120 a year in personal property tax for his aircraft, for a total of $11,700.
He was one of the founders of the Rockingham County Airport at Shiloh and the chairman of the airport authority there for about 10 years.
“However, I chose to hangar my aircraft in Danville because of its reasonable tax rate,” Smith wrote in the letter.
Jason Payne, who has stored his Pilatus plane at the Danville airport for four years, said he hopes Danville City Council will work out the tax rate. Payne said he paid about $25,000 in tax and for the hangar and light bill last year.
If the city raises the tax rate too much, Payne said he could build a runway and hangar on his property for about $32,000. Another option would be to register his aircraft in Delaware and pay no tax, he said.
“That hangar was vacant for nine years before I came there [at the Danville airport],” Payne said.
City Manager Ken Larking said all the hangars at the airport are booked and there is a waiting list for them, “so they’ll be quickly filled.”
A 90-cent increase would generate $30,000 in revenue a year, while 70 cents would bring in more than $20,000, Larking said.
Vogler said he opposes both the 90-cent and 70-cent rates.
“Even at the 70 per $100 increased rate … it represents the largest percentage tax increase in the entire budget, more than doubling the current rate,” Vogler said.
Also, it would bring in very little additional revenue, while more than likely costing money “through lost tax revenues and hangar fees when owners take their airplanes to other nearby airports,” Vogler said.
If council can’t find the money to save somewhere in the budget, “then we’re not doing our jobs. I will be voting against this tax increase,” Vogler said.
Original article can be found here: http://www.godanriver.com
Cessna 207A, Wings of Alaska, N62AK: Fatal accident occurred July 17, 2015 in Juneau, Alaska
Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf
NTSB Identification: ANC15FA049
Scheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Friday, July 17, 2015 in Juneau, AK
Probable Cause Approval Date: 04/19/2017
Aircraft: CESSNA 207A, registration: N62AK
Injuries: 1 Fatal, 4 Serious.
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 company flight coordinator on duty when the pilot got her "duty-on" briefing reported that, during the "duty-on" briefing, he informed the commercial pilot that most flights to the intended destination had been cancelled in the morning due to poor weather conditions and that one pilot had turned around due to weather. No record was found indicating that the pilot used the company computer to review weather information before the flight nor that she had received or retrieved any weather information before the flight. If she had obtained weather information, she would have seen that the weather was marginal visual flight rules to instrument flight rules conditions, which might have affected her decision to initiate the flight. The pilot subsequently departed for the scheduled commuter flight with four passengers on board; the flight was expected to be 20 minutes long.
Review of automatic dependent surveillance-broadcast data transmitted by the airplane showed that the airplane's flight track was farther north than the typical track for the destination and that the airplane did not turn south toward the destination after crossing the channel. Data from an onboard multifunction display showed that, as the airplane approached mountainous terrain on the west side of the channel, the airplane made a series of erratic pitch-and-roll maneuvers before it impacted trees and terrain. Postaccident examination of the airframe and engine revealed no mechanical malfunctions or anomalies that would have precluded normal operation. One of the passengers reported that, after takeoff, the turbulence was "heavy," and there were layers of fog and clouds and some rain. Based on the weather reports, the passenger statement regarding the weather, and the flight's erratic movement just before impact, it is likely that the flight encountered instrument meteorological conditions as it approached the mountainous terrain and that the pilot then lost situational awareness and flew into trees and terrain.
According to the company's General Operations Manual (GOM), operational control was delegated to the flight coordinator for the accident flight, and the flight coordinator and pilot-in-command (PIC) were jointly responsible for preflight planning, flight delay, and flight release, which included completing the flight risk assessment (FRA) process. This process required the PIC to fill out an FRA form and provide it to the flight coordinator before flight. However, the pilot did not fill out the form.
The GOM stated that one of the roles of the flight dispatcher (also referred to as "flight coordinator") was to assist the pilot in flight preparation by gathering and disseminating pertinent information regarding weather and any information deemed necessary for the safety of flight. It also stated that the dispatcher was to assist the PIC as necessary to ensure that all items required for flight preparation were accomplished before each flight. However, the flight coordinator did not discuss all the risks and weather conditions associated with the flight with the pilot, which was contrary to the GOM. When the flight coordinator who was on duty at the time the airplane was ready to depart did not receive a completed FRA, he did not stop the flight from departing, which was contrary to company policy. By not completing an FRA, it is likely the total risks associated with the accident flight were not adequately assessed. Neither the pilot nor the flight coordinator should have allowed the flight to be released without having completed an FRA form, which led to a loss of operational control and the failure to do so likely contributed to the accident.
Interviews with company personnel and a review of a sampling of FRA forms revealed that company personnel, including the flight coordinators, lacked a fundamental knowledge of operational control theory and practice and operational practices (or lack thereof), which led to a loss of operational control for the accident flight.
The company provided no formal flight coordinator training nor was a formal training program required. All of the company's qualified flight coordinators were delegated operational control and, thus, were required by 14 Code of Federal Regulations Section 119.69 to be qualified through training, experience, and expertise and to fully understand aviation safety standards and safe operating practice with respect to the company's operation and its GOM. However, the company had no formal method of documenting these requirements; therefore, it lacked a method of determining its flight coordinators' qualifications.
In postaccident interviews, the previous Federal Aviation Administration (FAA) principal operations inspector (POI), who became the frontline manager over the certificate, stated that the company used the minimum regulatory standard when it came to ceiling and visibility requirements and that the company did not have any company minimums in place. He further stated that a cloud ceiling of 500 ft and 2 miles visibility would not allow for power-off glide to land even though the company was required to meet this regulation. When asked if he believed the practice of allowing the pilot to decide when to fly was adequate, he said it was not and there should have been route altitudes. However, no action was taken to change SeaPort's operations. The POI at the time of the accident stated that she was also aware that the company was operating contrary to federal regulatory standards for gliding distance to shore. A review of FAA surveillance activities of the company revealed that the POI provided surveillance of the company following the accident, including an operational control inspection, and noted deficiencies with the company's operational procedures; however, the FAA did not hold the company accountable for correcting the identified operational deficiencies.
If the FAA had conducted an investigation or initiated an enforcement action pertaining to the company's apparent disregard of the regulatory standard for maintaining glide distance before the accident similar to the inspection conducted following the accident, it is plausible the flight would not have departed or continued when glide distance could not be maintained. The FAA's failure to ensure that the company corrected these deficiencies likely contributed to this accident which resulted, in part, from the company's failure to comply with its GOM and applicable federal regulations, including required glide distance to shore. The company was the holder of a Medallion Shield until they voluntarily suspended the Shield status but retained the "Star" status and continued advertising as a Shield carrier. Medallion stated in an email "With this process of voluntarily suspension, there will be no official communication to the FAA…" Given that Medallion advertises that along with the Shield comes recognition by the FAA as an operator who incorporates higher standards of safety, it seems contrary to safety that they would withhold information pertaining to a suspension of that status.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot's decision to initiate and continue visual flight into instrument meteorological conditions, which resulted in a loss of situational awareness and controlled flight into terrain. Contributing to the accident were the company's failure to follow its operational control and flight release procedures and its inadequate training and oversight of operational control personnel. Also contributing to the accident was the Federal Aviation Administration's failure to hold the company accountable for correcting known regulatory deficiencies and ensuring that it complied with its operational control procedures.
On June 25, 2015, a de Havilland Otter operated by Promech Air crashed in Misty Fjords National Monument. The pilot and all eight passengers were killed.
Three weeks later, on July 17, a Wings of Alaska Cessna 207 on a scheduled flight from Juneau to Hoonah crashed into mountainous terrain. The pilot was killed and four passengers seriously injured.
The Promech and Wings crashes had something notable in common: Both companies were members of the Medallion Foundation.
Medallion was formed as a nonprofit by the Alaska Air Carriers Association in 2001 to "improve pilot safety awareness and reduce air carrier insurance rates." Through the direction of the late Sen. Ted Stevens, the nonprofit organization received an initial federal grant of $3 million dollars in 2002.
According to budget requests later filed with the state, Medallion received $17 million in federal funds by 2013.
More recently, the organization has also received more than $750,000 from the state.
According to publicly filed records, an average of 44 percent of Medallion's annual income pays salaries. This does not include other administrative expenses or the minimum of $60,000 paid annually since 2013 for rental of a building owned by Executive Director Gerard Rock, where the foundation's offices are located.
Cornerstone safety programs
Medallion has developed safety programs in five key areas: CFIT (controlled flight into terrain) avoidance, operational control, maintenance and ground service, safety, and internal evaluation.
By completing each "cornerstone," members receive specific Medallion Stars. Those completing all five Stars are then eligible for a Shield after further evaluation.
Current Star and Shield members include Air Excursions, Alaska Central Express, Coastal Helicopters, Grant Aviation, Hageland Aviation, Pacific Airways, Ryan Air, Smokey Bay Air, Taquan Air and Wright Air Service, all of which have suffered accidents with fatalities or serious injuries in the past 10 years.
On its website, the organization points to escalating accident statistics in the 1990s as an impetus to its formation.
According to the National Transportation Safety Board database, in the 10-year period between Jan. 1, 1990, and the last day of 1999 there were 1,733 aircraft accidents in Alaska; 377 of them involved air taxis and small commuters (FAR Part 135 operators).
In the 10-year period after Medallion was founded, from Jan. 1, 2001, to the last day of 2010, there were 1,138 total aircraft accidents; 212 involving air taxis and small commuters.
However, it must be noted there was a far more dramatic impact on the Alaska aviation industry in this period than Medallion.
In 2002, Sen. Stevens spearheaded the passage of the Rural Service Improvement Act. Aimed at stabilizing the passenger, freight and mail system for rural Alaska, RSIA restructured how mail contracts were awarded and resulted in more than two dozen scheduled air carriers going out of business or being purchased by competitors.
The impact of the act on Alaska's aviation landscape cannot be overstated, nor can technological innovations such as Capstone and expansion of the FAA's weather-reporting system be ignored. Medallion does not exist in a vacuum and it would be inaccurate to suggest it is solely, or even primarily, responsible for an overall reduction in accidents.
‘Illusion of safety?’
Most third-party safety organizations like Medallion developed in recent years as air carriers sought to combat rising insurance rates. Generally, they issue public awards, like Stars and Shields, for completion of administered materials.
Recently, the NTSB criticized one such organization, Argus International, after a multiple fatality accident in Ohio. Board Member Robert Sumwalt stated Argus, which had been awarded a "Gold" rating to the charter company involved in the crash, provided only an "illusion of safety" to the aircraft's passengers.
A similar perceived sense of security was evident in Alaska in 2013 when Gov. Sean Parnell spoke to the Chamber of Commerce.
"Medallion certification diminishes the number of lost lives and injuries due to aviation accidents," Parnell said. "So if you are traveling on a Medallion-certified air carrier, you are traveling with people who have been trained above and beyond the minimum."
Ten people were killed in crashes involving Medallion members that year.
The reliance on third parties to provide assurance to passengers was touched on by Medallion's Rock in an interview with the NTSB following the 2013 triple fatality crash of Helo-1, a Department of Public Safety Eurocopter AS350 operated by the Alaska State Troopers. (The Department of Public Safety held a Medallion Safety Star.)
As Rock told investigators:"… A couple of these industries now require anybody flying for them, that they participate in Medallion for flying in Alaska. And I would say the main reason for that, when you look at the oil industry and the mining industry, most of these companies are from Outside and don't have a lot of Alaska safety experience, don't have winter operation experience. And Medallion gives them a tool to make sure the carriers flying for them here in Alaska actually kind of meet the requirements of flying, you know, in this type of environment."
There were problems with Medallion at the Department of Public Safety, however. According to the recently retired aviation section supervisor, the pilots were not involved in the new safety program.
"I don't feel like people really participated in it," she told investigators. "… I couldn't seem to get the trooper pilots to be into it."
The director of the Alaska Wildlife Troopers (who oversaw the aviation section), told investigators: "… Thinking back over these safety meetings, a lot of it was not even aviation related. It was, you know, like ice falling off a roof or, you know, maybe how fuel may have been stored. I don't recall ever seeing one flight-type safety issue."
In its investigation of the Helo-1 crash, the NTSB found in addition to errors by the pilot, there was "… inadequate safety management, which prevented the organization from identifying and correcting latent deficiencies in risk management and pilot training."
Membership intact
Medallion's influence was also studied in the investigations into the Promech and Wings of Alaska accidents, where there was some public confusion over their Medallion status.
In a 2016 interview with Alaska Dispatch News, Rock stated both companies "failed audits required to maintain membership and were on a yearlong suspension to correct deficiencies."
However, the NTSB report on the Wings crash includes a series of email exchanges between Medallion and Wings' owner, SeaPort Airlines, two months before the Hoonah accident. Those exchanges resulted in a voluntary suspension of the Shield but retention of the five Stars. The company's Medallion membership remained intact.
In the Promech investigation, its company president stated they held the CFIT Star and were in the process of obtaining the Safety Star. As that report notes, there was no evidence of Promech's Medallion membership status being suspended.
Rather, the foundation refused to respond to multiple NTSB requests "regarding Promech's external and internal Medallion audits…"
Those investigations made clear that both companies struggled with decision-making, as well as suffering operational control and apparent FAA oversight failures. Further, the circumstances surrounding the Promech crash in particular, which involved a line of air tour carriers following a pre-established route in marginal weather conditions, are familiar.
They echo previous "follow-the-leader" accidents including the 1994 crash of Wings of Alaska enroute to Juneau (seven dead, four seriously injured), the 1995 crash of Island Air Services in Kodiak (four dead), and the 2007 crash of Taquan Air in Misty Fjords (five dead).
‘Pilots just make mistakes’
In all of those accidents, as in nearly all of the finalized reports for fatality crashes in the past 10 years involving Medallion members (in one accident, the cause is unknown as the aircraft was unrecoverable), the probable causes were due to errors committed by the pilot. During the Helo-1 investigation, Bob Gastrock, a Medallion senior program manager, addressed this topic:
"And, you know, the pilot decision processes sometimes probably — I hate to say it, but 90 percent of the time, really why these accidents happen, I don't think it's so much the operator. The operator themself (sic) management, provides the tools, the training, but sometimes pilots just make mistakes and unfortunately that's just kind of what leads (to) this."
The NTSB recently determined the causes for both the Promech Air and Wings of Alaska crashes were the pilot's decisions to fly under visual flight rules into instrument meteorological conditions.
There were contributing factors as well, including, in the case of the Wings crash, the FAA's failure to properly monitor the company, and the company's failure to follow its own operational control procedures.
For Promech Air, the board also cited a corporate culture that "tacitly endorsed flying in hazardous weather and failed to manage the risks associated with the competitive pressures affecting Ketchikan-area air tour operators."
Are the programs working?
There are many questions to be raised about the effectiveness of the Medallion Foundation's programs on the recurrent problems plaguing Alaska aviation, and it is doubtful its standardized programs are addressing the issue of individual decision-making with actual pilots themselves.
Medallion supporters need to think about the failures among the foundation's membership and what that says about the organization's methods. At some point, it must be asked if the programs are working to increase flight safety, or serve more to impress unwitting passengers, federal investigators and insurers.
The brutal truth is what happened to Promech Air and Wings of Alaska in 2015 was just more of what has been happening in the state for decades. It was happening before the funding of millions of dollars and the awarding of Stars and Shields, and it shows no signs of stopping.
In May 2016, the FAA issued a letter to the more than 200 regional operators in Alaska. In the wake of five serious crashes dating back to Promech, the agency noted such accidents generally occur due to "inappropriate or nonexistent safety cultures…"
The agency encouraged companies to seek the assistance of the Medallion Foundation.
What the FAA failed to note was three of those accidents, like so many before them, involved Medallion members.
Colleen Mondor is the author of "The Map of My Dead Pilots: The Dangerous Game of Flying in Alaska."
Original article can be found here: https://www.adn.com
NTSB Identification: ANC15MA041
Nonscheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Thursday, June 25, 2015 in Ketchikan, AK
Aircraft: DEHAVILLAND DHC 3, registration: N270PA
Injuries: 9 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 traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report.
On June 25, 2015, about 1215 Alaska daylight time, a single-engine, turbine-powered, float-equipped de Havilland DHC-3 (Otter) airplane, N270PA, sustained substantial damage when it impacted mountainous tree-covered terrain, about 24 miles northeast of Ketchikan, Alaska. The airplane was being operated under the provisions of 14 Code of Federal Regulations (CFR) Part 135, as an on-demand visual flight rules (VFR) sightseeing flight when the accident occurred. The airplane was owned by Pantechnicon Aviation, of Minden, Nevada, and operated by Promech Air, Inc., of Ketchikan. The commercial pilot and eight passengers were fatally injured. Marginal visual meteorological conditions were reported in the area at the time of the accident. The flight departed a floating dock located in Rudyerd Bay about 44 miles northeast of Ketchikan about 1200 for a tour through Misty Fjords National Monument Wilderness. A company VFR flight plan was in effect. At the time of the accident, the flight was returning to the operator's base at the Ketchikan Harbor Seaplane Base, Ketchikan.
The flight was a sightseeing flight for passengers of a cruise ship that was docked in Ketchikan. The tour, named Cruise/Fly, consisted of two groups of passengers. One group departed Ketchikan onboard a marine vessel and the other group departed via airplane, with a predetermined rendezvous at the floating dock in Rudyerd Bay. Once at the floating dock, the two groups would switch transportation modes for the return trip to Ketchikan.
The operator reported that the accident airplane departed Rudyerd Bay as the third of four float-equipped airplanes on air tour flights over the Misty Fjords National Monument Wilderness. The airplanes departed about 5 minutes apart, and the standard route of flight was southwest, over an area of remote inland fjords, coastal waterways, and mountainous tree-covered terrain.
When the airplane failed to return to Ketchikan, the operator initiated a search for the missing airplane and heard an emergency locator transmitter (ELT) signal along the accident pilot's anticipated route of flight. A helicopter from Temsco Helicopters, Inc., of Ketchikan, was dispatched to the suspected accident site to search for the missing airplane. However, the helicopter pilot said that he was unable to search the upper levels of the mountainous areas due to low ceilings and poor visibility. The helicopter pilot said that, after waiting for the weather conditions to improve, he was able to search the upper elevations of the search area and located the wreckage about 1429. The Ketchikan Volunteer Rescue Squad (KVRS) team members reached the accident site and confirmed that the airplane's occupants had sustained fatal injuries.
The NTSB investigator-in-charge along with another NTSB investigator, with help from KVRS, reached the accident site on the morning of June 27. The airplane impacted trees and a near vertical rock face in a nose high, wings level attitude at an elevation of about 1,600 feet mean sea level and came to rest upright on top of its separated floats, in an area of heavily forested, steep terrain.
The accident airplane was equipped with an avionics package known as automatic dependent surveillance-broadcast (ADS-B), which is also known as "Capstone." ADS-B technology provides pilots with situational awareness by displaying the airplane's position over terrain, while using GPS technology, coupled with an instrument panel mounted, moving map display. The ADS-B equipment installed in the accident airplane included two Chelton multifunction display (MFD) units. One MFD provides the pilot with a moving map with terrain awareness information, and the other provides primary flight display information. The two MFD units were removed from the wreckage and shipped, to the NTSB vehicle recorder laboratory, Washington, D.C.
The accident airplane was equipped with a Pratt & Whitney PT6A-135A engine that produces 750 shaft horsepower.
A comprehensive NTSB postaccident examination of the engine and airframe is pending, after the airplane wreckage is recovered to Ketchikan.
The closest weather reporting facility is Ketchikan Airport (KTN), Ketchikan, AK, about 24 miles southwest of the accident site. At 1153, an aviation routine weather report (METAR) at KTN reported in part: wind 130 degrees at 15 knots, gust 23 knots; visibility 6 statute miles, rain and mist, runway 11 visual range 4,000 variable to greater than 6,000 feet; few clouds 800 feet, broken clouds 1,200 feet, overcast clouds 2,700 feet; 61 degrees F; dew point 57 degrees F; altimeter 29.91 in Hg.
NTSB Identification: ANC15FA049
Scheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Friday, July 17, 2015 in Juneau, AK
Probable Cause Approval Date: 04/19/2017
Aircraft: CESSNA 207A, registration: N62AK
Injuries: 1 Fatal, 4 Serious.
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 company flight coordinator on duty when the pilot got her "duty-on" briefing reported that, during the "duty-on" briefing, he informed the commercial pilot that most flights to the intended destination had been cancelled in the morning due to poor weather conditions and that one pilot had turned around due to weather. No record was found indicating that the pilot used the company computer to review weather information before the flight nor that she had received or retrieved any weather information before the flight. If she had obtained weather information, she would have seen that the weather was marginal visual flight rules to instrument flight rules conditions, which might have affected her decision to initiate the flight. The pilot subsequently departed for the scheduled commuter flight with four passengers on board; the flight was expected to be 20 minutes long.
Review of automatic dependent surveillance-broadcast data transmitted by the airplane showed that the airplane's flight track was farther north than the typical track for the destination and that the airplane did not turn south toward the destination after crossing the channel. Data from an onboard multifunction display showed that, as the airplane approached mountainous terrain on the west side of the channel, the airplane made a series of erratic pitch-and-roll maneuvers before it impacted trees and terrain. Postaccident examination of the airframe and engine revealed no mechanical malfunctions or anomalies that would have precluded normal operation. One of the passengers reported that, after takeoff, the turbulence was "heavy," and there were layers of fog and clouds and some rain. Based on the weather reports, the passenger statement regarding the weather, and the flight's erratic movement just before impact, it is likely that the flight encountered instrument meteorological conditions as it approached the mountainous terrain and that the pilot then lost situational awareness and flew into trees and terrain.
According to the company's General Operations Manual (GOM), operational control was delegated to the flight coordinator for the accident flight, and the flight coordinator and pilot-in-command (PIC) were jointly responsible for preflight planning, flight delay, and flight release, which included completing the flight risk assessment (FRA) process. This process required the PIC to fill out an FRA form and provide it to the flight coordinator before flight. However, the pilot did not fill out the form.
The GOM stated that one of the roles of the flight dispatcher (also referred to as "flight coordinator") was to assist the pilot in flight preparation by gathering and disseminating pertinent information regarding weather and any information deemed necessary for the safety of flight. It also stated that the dispatcher was to assist the PIC as necessary to ensure that all items required for flight preparation were accomplished before each flight. However, the flight coordinator did not discuss all the risks and weather conditions associated with the flight with the pilot, which was contrary to the GOM. When the flight coordinator who was on duty at the time the airplane was ready to depart did not receive a completed FRA, he did not stop the flight from departing, which was contrary to company policy. By not completing an FRA, it is likely the total risks associated with the accident flight were not adequately assessed. Neither the pilot nor the flight coordinator should have allowed the flight to be released without having completed an FRA form, which led to a loss of operational control and the failure to do so likely contributed to the accident.
Interviews with company personnel and a review of a sampling of FRA forms revealed that company personnel, including the flight coordinators, lacked a fundamental knowledge of operational control theory and practice and operational practices (or lack thereof), which led to a loss of operational control for the accident flight.
The company provided no formal flight coordinator training nor was a formal training program required. All of the company's qualified flight coordinators were delegated operational control and, thus, were required by 14 Code of Federal Regulations Section 119.69 to be qualified through training, experience, and expertise and to fully understand aviation safety standards and safe operating practice with respect to the company's operation and its GOM. However, the company had no formal method of documenting these requirements; therefore, it lacked a method of determining its flight coordinators' qualifications.
In postaccident interviews, the previous Federal Aviation Administration (FAA) principal operations inspector (POI), who became the frontline manager over the certificate, stated that the company used the minimum regulatory standard when it came to ceiling and visibility requirements and that the company did not have any company minimums in place. He further stated that a cloud ceiling of 500 ft and 2 miles visibility would not allow for power-off glide to land even though the company was required to meet this regulation. When asked if he believed the practice of allowing the pilot to decide when to fly was adequate, he said it was not and there should have been route altitudes. However, no action was taken to change SeaPort's operations. The POI at the time of the accident stated that she was also aware that the company was operating contrary to federal regulatory standards for gliding distance to shore. A review of FAA surveillance activities of the company revealed that the POI provided surveillance of the company following the accident, including an operational control inspection, and noted deficiencies with the company's operational procedures; however, the FAA did not hold the company accountable for correcting the identified operational deficiencies.
If the FAA had conducted an investigation or initiated an enforcement action pertaining to the company's apparent disregard of the regulatory standard for maintaining glide distance before the accident similar to the inspection conducted following the accident, it is plausible the flight would not have departed or continued when glide distance could not be maintained. The FAA's failure to ensure that the company corrected these deficiencies likely contributed to this accident which resulted, in part, from the company's failure to comply with its GOM and applicable federal regulations, including required glide distance to shore. The company was the holder of a Medallion Shield until they voluntarily suspended the Shield status but retained the "Star" status and continued advertising as a Shield carrier. Medallion stated in an email "With this process of voluntarily suspension, there will be no official communication to the FAA…" Given that Medallion advertises that along with the Shield comes recognition by the FAA as an operator who incorporates higher standards of safety, it seems contrary to safety that they would withhold information pertaining to a suspension of that status.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot's decision to initiate and continue visual flight into instrument meteorological conditions, which resulted in a loss of situational awareness and controlled flight into terrain. Contributing to the accident were the company's failure to follow its operational control and flight release procedures and its inadequate training and oversight of operational control personnel. Also contributing to the accident was the Federal Aviation Administration's failure to hold the company accountable for correcting known regulatory deficiencies and ensuring that it complied with its operational control procedures.
NTSB Identification: ANC15FA049
Scheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Friday, July 17, 2015 in Juneau, AK
Probable Cause Approval Date: 04/19/2017
Aircraft: CESSNA 207A, registration: N62AK
Injuries: 1 Fatal, 4 Serious.
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 company flight coordinator on duty when the pilot got her "duty-on" briefing reported that, during the "duty-on" briefing, he informed the commercial pilot that most flights to the intended destination had been cancelled in the morning due to poor weather conditions and that one pilot had turned around due to weather. No record was found indicating that the pilot used the company computer to review weather information before the flight nor that she had received or retrieved any weather information before the flight. If she had obtained weather information, she would have seen that the weather was marginal visual flight rules to instrument flight rules conditions, which might have affected her decision to initiate the flight. The pilot subsequently departed for the scheduled commuter flight with four passengers on board; the flight was expected to be 20 minutes long.
Review of automatic dependent surveillance-broadcast data transmitted by the airplane showed that the airplane's flight track was farther north than the typical track for the destination and that the airplane did not turn south toward the destination after crossing the channel. Data from an onboard multifunction display showed that, as the airplane approached mountainous terrain on the west side of the channel, the airplane made a series of erratic pitch-and-roll maneuvers before it impacted trees and terrain. Postaccident examination of the airframe and engine revealed no mechanical malfunctions or anomalies that would have precluded normal operation. One of the passengers reported that, after takeoff, the turbulence was "heavy," and there were layers of fog and clouds and some rain. Based on the weather reports, the passenger statement regarding the weather, and the flight's erratic movement just before impact, it is likely that the flight encountered instrument meteorological conditions as it approached the mountainous terrain and that the pilot then lost situational awareness and flew into trees and terrain.
According to the company's General Operations Manual (GOM), operational control was delegated to the flight coordinator for the accident flight, and the flight coordinator and pilot-in-command (PIC) were jointly responsible for preflight planning, flight delay, and flight release, which included completing the flight risk assessment (FRA) process. This process required the PIC to fill out an FRA form and provide it to the flight coordinator before flight. However, the pilot did not fill out the form.
The GOM stated that one of the roles of the flight dispatcher (also referred to as "flight coordinator") was to assist the pilot in flight preparation by gathering and disseminating pertinent information regarding weather and any information deemed necessary for the safety of flight. It also stated that the dispatcher was to assist the PIC as necessary to ensure that all items required for flight preparation were accomplished before each flight. However, the flight coordinator did not discuss all the risks and weather conditions associated with the flight with the pilot, which was contrary to the GOM. When the flight coordinator who was on duty at the time the airplane was ready to depart did not receive a completed FRA, he did not stop the flight from departing, which was contrary to company policy. By not completing an FRA, it is likely the total risks associated with the accident flight were not adequately assessed. Neither the pilot nor the flight coordinator should have allowed the flight to be released without having completed an FRA form, which led to a loss of operational control and the failure to do so likely contributed to the accident.
Interviews with company personnel and a review of a sampling of FRA forms revealed that company personnel, including the flight coordinators, lacked a fundamental knowledge of operational control theory and practice and operational practices (or lack thereof), which led to a loss of operational control for the accident flight.
The company provided no formal flight coordinator training nor was a formal training program required. All of the company's qualified flight coordinators were delegated operational control and, thus, were required by 14 Code of Federal Regulations Section 119.69 to be qualified through training, experience, and expertise and to fully understand aviation safety standards and safe operating practice with respect to the company's operation and its GOM. However, the company had no formal method of documenting these requirements; therefore, it lacked a method of determining its flight coordinators' qualifications.
In postaccident interviews, the previous Federal Aviation Administration (FAA) principal operations inspector (POI), who became the frontline manager over the certificate, stated that the company used the minimum regulatory standard when it came to ceiling and visibility requirements and that the company did not have any company minimums in place. He further stated that a cloud ceiling of 500 ft and 2 miles visibility would not allow for power-off glide to land even though the company was required to meet this regulation. When asked if he believed the practice of allowing the pilot to decide when to fly was adequate, he said it was not and there should have been route altitudes. However, no action was taken to change SeaPort's operations. The POI at the time of the accident stated that she was also aware that the company was operating contrary to federal regulatory standards for gliding distance to shore. A review of FAA surveillance activities of the company revealed that the POI provided surveillance of the company following the accident, including an operational control inspection, and noted deficiencies with the company's operational procedures; however, the FAA did not hold the company accountable for correcting the identified operational deficiencies.
If the FAA had conducted an investigation or initiated an enforcement action pertaining to the company's apparent disregard of the regulatory standard for maintaining glide distance before the accident similar to the inspection conducted following the accident, it is plausible the flight would not have departed or continued when glide distance could not be maintained. The FAA's failure to ensure that the company corrected these deficiencies likely contributed to this accident which resulted, in part, from the company's failure to comply with its GOM and applicable federal regulations, including required glide distance to shore. The company was the holder of a Medallion Shield until they voluntarily suspended the Shield status but retained the "Star" status and continued advertising as a Shield carrier. Medallion stated in an email "With this process of voluntarily suspension, there will be no official communication to the FAA…" Given that Medallion advertises that along with the Shield comes recognition by the FAA as an operator who incorporates higher standards of safety, it seems contrary to safety that they would withhold information pertaining to a suspension of that status.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot's decision to initiate and continue visual flight into instrument meteorological conditions, which resulted in a loss of situational awareness and controlled flight into terrain. Contributing to the accident were the company's failure to follow its operational control and flight release procedures and its inadequate training and oversight of operational control personnel. Also contributing to the accident was the Federal Aviation Administration's failure to hold the company accountable for correcting known regulatory deficiencies and ensuring that it complied with its operational control procedures.
Three weeks later, on July 17, a Wings of Alaska Cessna 207 on a scheduled flight from Juneau to Hoonah crashed into mountainous terrain. The pilot was killed and four passengers seriously injured.
The Promech and Wings crashes had something notable in common: Both companies were members of the Medallion Foundation.
Medallion was formed as a nonprofit by the Alaska Air Carriers Association in 2001 to "improve pilot safety awareness and reduce air carrier insurance rates." Through the direction of the late Sen. Ted Stevens, the nonprofit organization received an initial federal grant of $3 million dollars in 2002.
According to budget requests later filed with the state, Medallion received $17 million in federal funds by 2013.
More recently, the organization has also received more than $750,000 from the state.
According to publicly filed records, an average of 44 percent of Medallion's annual income pays salaries. This does not include other administrative expenses or the minimum of $60,000 paid annually since 2013 for rental of a building owned by Executive Director Gerard Rock, where the foundation's offices are located.
Cornerstone safety programs
Medallion has developed safety programs in five key areas: CFIT (controlled flight into terrain) avoidance, operational control, maintenance and ground service, safety, and internal evaluation.
By completing each "cornerstone," members receive specific Medallion Stars. Those completing all five Stars are then eligible for a Shield after further evaluation.
Current Star and Shield members include Air Excursions, Alaska Central Express, Coastal Helicopters, Grant Aviation, Hageland Aviation, Pacific Airways, Ryan Air, Smokey Bay Air, Taquan Air and Wright Air Service, all of which have suffered accidents with fatalities or serious injuries in the past 10 years.
On its website, the organization points to escalating accident statistics in the 1990s as an impetus to its formation.
According to the National Transportation Safety Board database, in the 10-year period between Jan. 1, 1990, and the last day of 1999 there were 1,733 aircraft accidents in Alaska; 377 of them involved air taxis and small commuters (FAR Part 135 operators).
In the 10-year period after Medallion was founded, from Jan. 1, 2001, to the last day of 2010, there were 1,138 total aircraft accidents; 212 involving air taxis and small commuters.
However, it must be noted there was a far more dramatic impact on the Alaska aviation industry in this period than Medallion.
In 2002, Sen. Stevens spearheaded the passage of the Rural Service Improvement Act. Aimed at stabilizing the passenger, freight and mail system for rural Alaska, RSIA restructured how mail contracts were awarded and resulted in more than two dozen scheduled air carriers going out of business or being purchased by competitors.
The impact of the act on Alaska's aviation landscape cannot be overstated, nor can technological innovations such as Capstone and expansion of the FAA's weather-reporting system be ignored. Medallion does not exist in a vacuum and it would be inaccurate to suggest it is solely, or even primarily, responsible for an overall reduction in accidents.
‘Illusion of safety?’
Most third-party safety organizations like Medallion developed in recent years as air carriers sought to combat rising insurance rates. Generally, they issue public awards, like Stars and Shields, for completion of administered materials.
Recently, the NTSB criticized one such organization, Argus International, after a multiple fatality accident in Ohio. Board Member Robert Sumwalt stated Argus, which had been awarded a "Gold" rating to the charter company involved in the crash, provided only an "illusion of safety" to the aircraft's passengers.
A similar perceived sense of security was evident in Alaska in 2013 when Gov. Sean Parnell spoke to the Chamber of Commerce.
"Medallion certification diminishes the number of lost lives and injuries due to aviation accidents," Parnell said. "So if you are traveling on a Medallion-certified air carrier, you are traveling with people who have been trained above and beyond the minimum."
Ten people were killed in crashes involving Medallion members that year.
The reliance on third parties to provide assurance to passengers was touched on by Medallion's Rock in an interview with the NTSB following the 2013 triple fatality crash of Helo-1, a Department of Public Safety Eurocopter AS350 operated by the Alaska State Troopers. (The Department of Public Safety held a Medallion Safety Star.)
As Rock told investigators:"… A couple of these industries now require anybody flying for them, that they participate in Medallion for flying in Alaska. And I would say the main reason for that, when you look at the oil industry and the mining industry, most of these companies are from Outside and don't have a lot of Alaska safety experience, don't have winter operation experience. And Medallion gives them a tool to make sure the carriers flying for them here in Alaska actually kind of meet the requirements of flying, you know, in this type of environment."
There were problems with Medallion at the Department of Public Safety, however. According to the recently retired aviation section supervisor, the pilots were not involved in the new safety program.
"I don't feel like people really participated in it," she told investigators. "… I couldn't seem to get the trooper pilots to be into it."
The director of the Alaska Wildlife Troopers (who oversaw the aviation section), told investigators: "… Thinking back over these safety meetings, a lot of it was not even aviation related. It was, you know, like ice falling off a roof or, you know, maybe how fuel may have been stored. I don't recall ever seeing one flight-type safety issue."
In its investigation of the Helo-1 crash, the NTSB found in addition to errors by the pilot, there was "… inadequate safety management, which prevented the organization from identifying and correcting latent deficiencies in risk management and pilot training."
Membership intact
Medallion's influence was also studied in the investigations into the Promech and Wings of Alaska accidents, where there was some public confusion over their Medallion status.
In a 2016 interview with Alaska Dispatch News, Rock stated both companies "failed audits required to maintain membership and were on a yearlong suspension to correct deficiencies."
However, the NTSB report on the Wings crash includes a series of email exchanges between Medallion and Wings' owner, SeaPort Airlines, two months before the Hoonah accident. Those exchanges resulted in a voluntary suspension of the Shield but retention of the five Stars. The company's Medallion membership remained intact.
In the Promech investigation, its company president stated they held the CFIT Star and were in the process of obtaining the Safety Star. As that report notes, there was no evidence of Promech's Medallion membership status being suspended.
Rather, the foundation refused to respond to multiple NTSB requests "regarding Promech's external and internal Medallion audits…"
Those investigations made clear that both companies struggled with decision-making, as well as suffering operational control and apparent FAA oversight failures. Further, the circumstances surrounding the Promech crash in particular, which involved a line of air tour carriers following a pre-established route in marginal weather conditions, are familiar.
They echo previous "follow-the-leader" accidents including the 1994 crash of Wings of Alaska enroute to Juneau (seven dead, four seriously injured), the 1995 crash of Island Air Services in Kodiak (four dead), and the 2007 crash of Taquan Air in Misty Fjords (five dead).
‘Pilots just make mistakes’
In all of those accidents, as in nearly all of the finalized reports for fatality crashes in the past 10 years involving Medallion members (in one accident, the cause is unknown as the aircraft was unrecoverable), the probable causes were due to errors committed by the pilot. During the Helo-1 investigation, Bob Gastrock, a Medallion senior program manager, addressed this topic:
"And, you know, the pilot decision processes sometimes probably — I hate to say it, but 90 percent of the time, really why these accidents happen, I don't think it's so much the operator. The operator themself (sic) management, provides the tools, the training, but sometimes pilots just make mistakes and unfortunately that's just kind of what leads (to) this."
The NTSB recently determined the causes for both the Promech Air and Wings of Alaska crashes were the pilot's decisions to fly under visual flight rules into instrument meteorological conditions.
There were contributing factors as well, including, in the case of the Wings crash, the FAA's failure to properly monitor the company, and the company's failure to follow its own operational control procedures.
For Promech Air, the board also cited a corporate culture that "tacitly endorsed flying in hazardous weather and failed to manage the risks associated with the competitive pressures affecting Ketchikan-area air tour operators."
Are the programs working?
There are many questions to be raised about the effectiveness of the Medallion Foundation's programs on the recurrent problems plaguing Alaska aviation, and it is doubtful its standardized programs are addressing the issue of individual decision-making with actual pilots themselves.
Medallion supporters need to think about the failures among the foundation's membership and what that says about the organization's methods. At some point, it must be asked if the programs are working to increase flight safety, or serve more to impress unwitting passengers, federal investigators and insurers.
The brutal truth is what happened to Promech Air and Wings of Alaska in 2015 was just more of what has been happening in the state for decades. It was happening before the funding of millions of dollars and the awarding of Stars and Shields, and it shows no signs of stopping.
In May 2016, the FAA issued a letter to the more than 200 regional operators in Alaska. In the wake of five serious crashes dating back to Promech, the agency noted such accidents generally occur due to "inappropriate or nonexistent safety cultures…"
The agency encouraged companies to seek the assistance of the Medallion Foundation.
What the FAA failed to note was three of those accidents, like so many before them, involved Medallion members.
Colleen Mondor is the author of "The Map of My Dead Pilots: The Dangerous Game of Flying in Alaska."
Original article can be found here: https://www.adn.com
NTSB Identification: ANC15MA041
Nonscheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Thursday, June 25, 2015 in Ketchikan, AK
Aircraft: DEHAVILLAND DHC 3, registration: N270PA
Injuries: 9 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 traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report.
On June 25, 2015, about 1215 Alaska daylight time, a single-engine, turbine-powered, float-equipped de Havilland DHC-3 (Otter) airplane, N270PA, sustained substantial damage when it impacted mountainous tree-covered terrain, about 24 miles northeast of Ketchikan, Alaska. The airplane was being operated under the provisions of 14 Code of Federal Regulations (CFR) Part 135, as an on-demand visual flight rules (VFR) sightseeing flight when the accident occurred. The airplane was owned by Pantechnicon Aviation, of Minden, Nevada, and operated by Promech Air, Inc., of Ketchikan. The commercial pilot and eight passengers were fatally injured. Marginal visual meteorological conditions were reported in the area at the time of the accident. The flight departed a floating dock located in Rudyerd Bay about 44 miles northeast of Ketchikan about 1200 for a tour through Misty Fjords National Monument Wilderness. A company VFR flight plan was in effect. At the time of the accident, the flight was returning to the operator's base at the Ketchikan Harbor Seaplane Base, Ketchikan.
The flight was a sightseeing flight for passengers of a cruise ship that was docked in Ketchikan. The tour, named Cruise/Fly, consisted of two groups of passengers. One group departed Ketchikan onboard a marine vessel and the other group departed via airplane, with a predetermined rendezvous at the floating dock in Rudyerd Bay. Once at the floating dock, the two groups would switch transportation modes for the return trip to Ketchikan.
The operator reported that the accident airplane departed Rudyerd Bay as the third of four float-equipped airplanes on air tour flights over the Misty Fjords National Monument Wilderness. The airplanes departed about 5 minutes apart, and the standard route of flight was southwest, over an area of remote inland fjords, coastal waterways, and mountainous tree-covered terrain.
When the airplane failed to return to Ketchikan, the operator initiated a search for the missing airplane and heard an emergency locator transmitter (ELT) signal along the accident pilot's anticipated route of flight. A helicopter from Temsco Helicopters, Inc., of Ketchikan, was dispatched to the suspected accident site to search for the missing airplane. However, the helicopter pilot said that he was unable to search the upper levels of the mountainous areas due to low ceilings and poor visibility. The helicopter pilot said that, after waiting for the weather conditions to improve, he was able to search the upper elevations of the search area and located the wreckage about 1429. The Ketchikan Volunteer Rescue Squad (KVRS) team members reached the accident site and confirmed that the airplane's occupants had sustained fatal injuries.
The NTSB investigator-in-charge along with another NTSB investigator, with help from KVRS, reached the accident site on the morning of June 27. The airplane impacted trees and a near vertical rock face in a nose high, wings level attitude at an elevation of about 1,600 feet mean sea level and came to rest upright on top of its separated floats, in an area of heavily forested, steep terrain.
The accident airplane was equipped with an avionics package known as automatic dependent surveillance-broadcast (ADS-B), which is also known as "Capstone." ADS-B technology provides pilots with situational awareness by displaying the airplane's position over terrain, while using GPS technology, coupled with an instrument panel mounted, moving map display. The ADS-B equipment installed in the accident airplane included two Chelton multifunction display (MFD) units. One MFD provides the pilot with a moving map with terrain awareness information, and the other provides primary flight display information. The two MFD units were removed from the wreckage and shipped, to the NTSB vehicle recorder laboratory, Washington, D.C.
The accident airplane was equipped with a Pratt & Whitney PT6A-135A engine that produces 750 shaft horsepower.
A comprehensive NTSB postaccident examination of the engine and airframe is pending, after the airplane wreckage is recovered to Ketchikan.
The closest weather reporting facility is Ketchikan Airport (KTN), Ketchikan, AK, about 24 miles southwest of the accident site. At 1153, an aviation routine weather report (METAR) at KTN reported in part: wind 130 degrees at 15 knots, gust 23 knots; visibility 6 statute miles, rain and mist, runway 11 visual range 4,000 variable to greater than 6,000 feet; few clouds 800 feet, broken clouds 1,200 feet, overcast clouds 2,700 feet; 61 degrees F; dew point 57 degrees F; altimeter 29.91 in Hg.
NTSB Identification: ANC15FA049
Scheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Friday, July 17, 2015 in Juneau, AK
Probable Cause Approval Date: 04/19/2017
Aircraft: CESSNA 207A, registration: N62AK
Injuries: 1 Fatal, 4 Serious.
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 company flight coordinator on duty when the pilot got her "duty-on" briefing reported that, during the "duty-on" briefing, he informed the commercial pilot that most flights to the intended destination had been cancelled in the morning due to poor weather conditions and that one pilot had turned around due to weather. No record was found indicating that the pilot used the company computer to review weather information before the flight nor that she had received or retrieved any weather information before the flight. If she had obtained weather information, she would have seen that the weather was marginal visual flight rules to instrument flight rules conditions, which might have affected her decision to initiate the flight. The pilot subsequently departed for the scheduled commuter flight with four passengers on board; the flight was expected to be 20 minutes long.
Review of automatic dependent surveillance-broadcast data transmitted by the airplane showed that the airplane's flight track was farther north than the typical track for the destination and that the airplane did not turn south toward the destination after crossing the channel. Data from an onboard multifunction display showed that, as the airplane approached mountainous terrain on the west side of the channel, the airplane made a series of erratic pitch-and-roll maneuvers before it impacted trees and terrain. Postaccident examination of the airframe and engine revealed no mechanical malfunctions or anomalies that would have precluded normal operation. One of the passengers reported that, after takeoff, the turbulence was "heavy," and there were layers of fog and clouds and some rain. Based on the weather reports, the passenger statement regarding the weather, and the flight's erratic movement just before impact, it is likely that the flight encountered instrument meteorological conditions as it approached the mountainous terrain and that the pilot then lost situational awareness and flew into trees and terrain.
According to the company's General Operations Manual (GOM), operational control was delegated to the flight coordinator for the accident flight, and the flight coordinator and pilot-in-command (PIC) were jointly responsible for preflight planning, flight delay, and flight release, which included completing the flight risk assessment (FRA) process. This process required the PIC to fill out an FRA form and provide it to the flight coordinator before flight. However, the pilot did not fill out the form.
The GOM stated that one of the roles of the flight dispatcher (also referred to as "flight coordinator") was to assist the pilot in flight preparation by gathering and disseminating pertinent information regarding weather and any information deemed necessary for the safety of flight. It also stated that the dispatcher was to assist the PIC as necessary to ensure that all items required for flight preparation were accomplished before each flight. However, the flight coordinator did not discuss all the risks and weather conditions associated with the flight with the pilot, which was contrary to the GOM. When the flight coordinator who was on duty at the time the airplane was ready to depart did not receive a completed FRA, he did not stop the flight from departing, which was contrary to company policy. By not completing an FRA, it is likely the total risks associated with the accident flight were not adequately assessed. Neither the pilot nor the flight coordinator should have allowed the flight to be released without having completed an FRA form, which led to a loss of operational control and the failure to do so likely contributed to the accident.
Interviews with company personnel and a review of a sampling of FRA forms revealed that company personnel, including the flight coordinators, lacked a fundamental knowledge of operational control theory and practice and operational practices (or lack thereof), which led to a loss of operational control for the accident flight.
The company provided no formal flight coordinator training nor was a formal training program required. All of the company's qualified flight coordinators were delegated operational control and, thus, were required by 14 Code of Federal Regulations Section 119.69 to be qualified through training, experience, and expertise and to fully understand aviation safety standards and safe operating practice with respect to the company's operation and its GOM. However, the company had no formal method of documenting these requirements; therefore, it lacked a method of determining its flight coordinators' qualifications.
In postaccident interviews, the previous Federal Aviation Administration (FAA) principal operations inspector (POI), who became the frontline manager over the certificate, stated that the company used the minimum regulatory standard when it came to ceiling and visibility requirements and that the company did not have any company minimums in place. He further stated that a cloud ceiling of 500 ft and 2 miles visibility would not allow for power-off glide to land even though the company was required to meet this regulation. When asked if he believed the practice of allowing the pilot to decide when to fly was adequate, he said it was not and there should have been route altitudes. However, no action was taken to change SeaPort's operations. The POI at the time of the accident stated that she was also aware that the company was operating contrary to federal regulatory standards for gliding distance to shore. A review of FAA surveillance activities of the company revealed that the POI provided surveillance of the company following the accident, including an operational control inspection, and noted deficiencies with the company's operational procedures; however, the FAA did not hold the company accountable for correcting the identified operational deficiencies.
If the FAA had conducted an investigation or initiated an enforcement action pertaining to the company's apparent disregard of the regulatory standard for maintaining glide distance before the accident similar to the inspection conducted following the accident, it is plausible the flight would not have departed or continued when glide distance could not be maintained. The FAA's failure to ensure that the company corrected these deficiencies likely contributed to this accident which resulted, in part, from the company's failure to comply with its GOM and applicable federal regulations, including required glide distance to shore. The company was the holder of a Medallion Shield until they voluntarily suspended the Shield status but retained the "Star" status and continued advertising as a Shield carrier. Medallion stated in an email "With this process of voluntarily suspension, there will be no official communication to the FAA…" Given that Medallion advertises that along with the Shield comes recognition by the FAA as an operator who incorporates higher standards of safety, it seems contrary to safety that they would withhold information pertaining to a suspension of that status.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot's decision to initiate and continue visual flight into instrument meteorological conditions, which resulted in a loss of situational awareness and controlled flight into terrain. Contributing to the accident were the company's failure to follow its operational control and flight release procedures and its inadequate training and oversight of operational control personnel. Also contributing to the accident was the Federal Aviation Administration's failure to hold the company accountable for correcting known regulatory deficiencies and ensuring that it complied with its operational control procedures.
Slingsby T67M-260 Firefly, N456FR, registered to L'Avion Inc, operated by National Test Pilot School: Fatal accident occurred October 24, 2014 in Ridgecrest, Kern County, California
Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf
NTSB Identification: WPR15FA021
14 CFR Part 91: General Aviation
Accident occurred Friday, October 24, 2014 in Ridgecrest, CA
Probable Cause Approval Date: 05/23/2017
Aircraft: SLINGSBY T67M 260, registration: N456FR
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 flight instructor and student, who was receiving instruction as part of a Flight Test Engineer program, departed with the intent of completing a flight card that called for 10 maneuvers, 4 of which included spins for a certain amount of rotations. The program allowed students to fly the airplane if they felt comfortable; however, it did not require that the student fly the airplane. A camera mounted inside the airplane provided a view of the right wing. Review of the recorded video revealed that the flight performed two left spins and one right spin with uneventful recoveries before the accident sequence.
The video showed that, during the accident sequence, the airplane entered a right spin, consistent with a maneuver on the flight card, which called for a six-rotation right spin with aileron inputs before recovery. Throughout the spin sequence, little-to-no aileron input was observed. As the airplane completed about 21 revolutions, the student made an altitude call of "6,000 ft," which was the specified bailout altitude. Shortly after, a callout of "5,500 ft" was made during revolution 22, and the canopy was opened between revolutions 24 and 25. Reflections within the canopy showed the student standing while grabbing the upper canopy rail between revolutions 29 and 30 and subsequently jumping from the right wing between revolutions 33 and 34. At the time of ground impact, the airplane had completed about 34 revolutions. The delayed egress from the airplane below the specified egression altitude and just before impact likely contributed to the student's fatal injuries. Little-to-no movement of the flight instructor was observed on the video; thus it is likely he did not attempt to bailout of the airplane.
Postaccident examination of the airframe and engine revealed no evidence of any preexisting mechanical malfunctions that would have precluded normal operation. In addition, the airplane was found to be within weight-and-balance and center-of-gravity limits. Further, a recent inspection of the airplane's rigging revealed that it was within limits prior to the accident flight. The accident circumstances are consistent with the pilots' failure to recover from a spin; however, the reason for this could not be determined.
Although the flight instructor's toxicology testing detected ethanol in the kidney, the absence of ethanol in the muscle suggests the identified ethanol was likely from postmortem production rather than ingestion. Although the autopsy of the flight instructor identified left ventricular hypertrophy, which is most often associated with hypertension, age, or regular, vigorous exercise and may be associated with an increased risk for acute cardiovascular events, only mild coronary artery disease and no significant atherosclerosis were noted. However, if a cardiovascular event or loss of consciousness from any other cause (such as a seizure or neurogenic syncope) occurred in the few minutes before the flight instructor's death, it would have left no evidence on autopsy.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilots' failure to recover from a spin for reasons that could not be determined based on available information. Contributing to the student's fatal injury was his delayed egress from the airplane below the specified egression altitude.
The National Transportation Safety Board traveled to the scene of this accident.
Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Van Nuys, California
Lycoming Engines; Williamsport, Pennsylvania
Flight Research Inc.; Mojave, California
National Test Pilot School; Mojave, California
Aviation Accident Factual Report - National Transportation Safety Board: https://app.ntsb.gov/pdf
Registered to L'Avion, Inc., Mojave, California
Operated by the National Test Pilot School (NTPS)
http://registry.faa.gov/N456FR
NTSB Identification: WPR15FA021
14 CFR Part 91: General Aviation
Accident occurred Friday, October 24, 2014 in Ridgecrest, CA
Aircraft: SLINGSBY T67M 260, registration: N456FR
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 October 24, 2014, about 0900 Pacific daylight time, a Slingsby T67M-260, N456FR, impacted terrain near Ridgecrest, California. The flight instructor and student were fatally injured, and the airplane sustained substantial damage. The airplane was registered to L'Avion, Inc., Mojave, California, and was being operated by the National Test Pilot School (NTPS) as a 14 Code of Federal Regulations Part 91 instructional flight. Visual meteorological conditions existed near the accident site about the time of the accident, and no flight plan was filed. The local flight originated from Mojave Airport, Mojave, California, about 0832.
NTPS representatives provided information to the National Transportation Safety Board (NTSB) investigator-in-charge (IIC) that indicated that the flight was part of the Flight Test Engineer Training Program, which includes the Basic Flight Awareness Program (BFAP). The purpose of the flight was to perform a series of stalls and spins. After air traffic controllers lost radar and radio contact with the airplane, a search was initiated, and the wreckage was subsequently located by a pilot in a company aircraft. Review of radar data provided by the Federal Aviation Administration (FAA) revealed that the airplane was at an altitude of about 11,800 ft mean sea level (msl) before it began a spin sequence and crashed.
Another flight instructor reported that he had flown with the student 3 days before the accident in a different airplane of the same make and model. The instructor stated that the flight was BFAP Flight 9 (F9) and that the student was flying the airplane during a phase-c stall, which included a 3-second application of full left rudder and full aft control stick inputs. During the maneuver, the airplane did not recover as expected, and the instructor ordered the student to initiate recovery from a spin per the flight manual procedures. Following two more rotations and proper recovery technique by the student, the airplane continued in a left spin. The flight instructor took control of the airplane and applied spin recovery control inputs. The airplane continued to spin an additional two rotations before the instructor applied full opposite rudder and full aft stick, reinitiating the flight manual recovery procedure with the use of more forward stick inputs at a faster rate.
The instructor further reported that, following two additional revolutions, the airplane did not recover, and that he immediately applied full aft stick, full opposite aileron, and "slammed" the control stick full forward in an effort to recover from the spin. The instructor stated that the airplane went into an almost 90°-nose-down attitude and that he recovered about 200 ft above the minimum bailout altitude. The instructor terminated the flight and returned to the departure airport. During the return flight, the instructor noted no evidence of any flight control binding or interference.
The President of NTPS reported that, due to the instructor's difficulty recovering from the spin, the school grounded both of its T67M-260 airplanes to verify their flight control rigging. He reported that the T67M-260 that the student had flown 3 days before the accident was found to be at the maximum rigging limits. Maintenance personnel corrected the rigging, and the airplane was returned to service. He reported that the rigging on the accident airplane was found to be well within limits and that it was subsequently returned to service. He further reported that the accident airplane had been spun hundreds of times by various flight instructors and students with no issues before the accident flight. The NTPS Chief of Operations further reported that, when the accident airplane was returned to service, he had scheduled the student with the accident flight instructor, who had vast experience with spins in propeller-driven aircraft.
PERSONNEL INFORMATION
The flight instructor, age 68, held an airline transport pilot certificate with an airplane multiengine land rating with commercial pilot privileges for airplane single-engine land, rotorcraft helicopter, and instrument helicopter. The flight instructor was issued a second-class airman medical certificate on January 16, 2014, with no limitations. At the time of his most recent medical application, the flight instructor reported that he had accumulated a total flight time of 7,845 hours.
Review of the pilot's logbook with entries dated from December 5, 2012, to October 8, 2014, revealed that his most recent flight review was completed on September 10, 2013, in a Piper PA-34. Between January 1, 2014, and October 8, 2014, the flight instructor had logged a total of 160.3 flight hours, which included 49.9 hours in airplanes, 5.3 hours of which were in the accident make/model airplane, and 94.6 hours in helicopters. Within the 90 days before the accident, the flight instructor had logged 2.3 hours in the accident airplane on October 7 and 8, 2014. Per an entry dated April 15, 2014, the flight instructor flew the accident airplane for 1 hour, with "spins" noted in the comment section. It could not be determined how much total flight time the flight instructor had in the accident make/model airplane. NTPS representatives reported that the flight instructor had previous military flight experience in both fixed-wing aircraft and rotorcraft. As part of his military flight experience, he was a primary flight instructor in T-34C airplanes. In addition, the flight instructor had been employed with NTPS since January 2006.
The student did not hold any flight or medical certificates. However, the student was a student of the Flight Test Engineer training program, which allowed nonpilot-rated students to conduct the specified maneuvers if they felt comfortable doing so. It could not be determined how much actual flight experience the student accumulated while enrolled in the program.
AIRCRAFT INFORMATION
The two-seat, low-wing, fixed-gear airplane, serial number (S/N) 2257, was manufactured in 1996. It was powered by a 260-horsepower Lycoming AEIO-540-D4A5 engine, serial number L-25838-48A, and was equipped with a three-bladed Hoffman adjustable-pitch propeller. Review of airframe and engine logbook records revealed that the most recent annual inspection was completed on August 6, 2014, at an airframe total time of 5,104.8 hours.
Using the reported weights of both occupants and full fuel, the airplane was found to be within weight-and-balance and center-of-gravity limits.
METEOROLOGICAL INFORMATION
At 0855, recorded weather from a station located about 27 miles southwest of the accident site reported calm wind, visibility 10 statute miles, clear sky, temperature 15° C, dew point -4° C, and an altimeter setting of 30.09 inches of mercury.
WRECKAGE AND IMPACT INFORMATION
Representatives of the FAA and NTSB conducted an on-scene examination of the accident site on October 24 and 25, 2014.
Examination of the accident site revealed that the airplane impacted open desert terrain about 12 miles south of Ridgecrest. The airplane came to rest upright oriented on a magnetic heading of about 027° at a GPS elevation of 2,345 ft msl. Wreckage debris, which included plexiglass, rudder, and portions of the engine cowling, remained within about 10 ft of the main wreckage. Vegetation, about 12 to 18 inches high and located immediately to the left and right of the aft area of the fuselage, appeared to be undamaged.
The left wing remained attached to the fuselage. The left aileron remained attached to its respective mounts. The outboard portion of the left flap was separated and located about 1 ft aft of the left wing. The inboard portion of the flap remained attached via the inboard attachment point. The right wing remained attached to the fuselage. The right aileron remained attached to its respective mounts. The outboard portion of the right flap was separated at the outboard attachment mount and remained attached to the inboard portion of the flap. The inboard portion of the flap remained attached via the inboard attachment point.
The empennage remained intact. The left and right horizontal stabilizers remained attached. The left and right elevators remained attached via their respective mounts. The trim tab remained attached via its respective mount. The rudder was separated from the vertical stabilizer at the upper hinge attachment point, and the separated portion of the rudder was located about 1 ft aft of the main wreckage. The bottom portion of the rudder, which included the rudder bellcrank, remained attached to the vertical stabilizer.
Flight control continuity was established from the cockpit controls to all primary control surfaces. No breaks or separations were observed within the entire flight control system.
The fuselage appeared to be intact with displaced portions of the composite structure aft of the cockpit area, consistent with impact-related forces. An additional separation of the fuselage (crack) was observed immediately aft of the seats. Dirt/sand was observed on the right side of the cowling, and it was built up higher than on the wing's left side.
Documentation of the cockpit area revealed that both the left and right seat five-point restraints remained attached to the fuselage attachment points; however, all harnesses were separated from the clasp assembly. The left seat shoulder restraint metal clasp was found partially embedded in the outside portion of the fuselage.
The cabin area remained intact, and the canopy was separated. The aft canopy slide mechanism was located in an "aft" position, consistent with the canopy being in an "open" position. The canopy slide lock was found in the "unlocked" position.
The wreckage was recovered to a secure location for further examination; both wings, horizontal stabilizers, and elevators were removed to facilitate transport of the wreckage. Examination of the recovered wreckage was conducted at the facilities of Air Transport, Phoenix, Arizona, on December 11, 2014, by the NTSB IIC and a representative from Lycoming Engines.
No evidence of binding or restricted travel was observed. The left seat control stick was fractured at the base. The fracture surfaces exhibited signatures consistent with overload separation.
Examination of the recovered engine revealed that all engine accessories remained attached to the engine except for the right magneto, oil filter, vacuum pump, and fuel control servo. The rocker box covers, left magneto, and top spark plugs were removed. The crankshaft was rotated using a hand tool attached to one of the accessory case drive pads. Rotational continuity was established throughout the engine and valve train, and thumb compression was obtained on all six cylinders. Both the left and right magnetos were intact and produced spark on all posts when the magneto drive shafts were rotated using a hand drill.
For further information regarding the airframe and engine examination, see the NTSB Accident Site, Airframe, and Engine Examination Summary Report within the public docket for this accident.
MEDICAL AND PATHOLOGICAL INFORMATION
Flight Instructor
According to the Kern County Coroner's autopsy report, the flight instructor's cause of death was "multiple blunt force trauma," and the manner of death was "accident." Examination of the body identified left ventricular hypertrophy, which is most often associated with hypertension, age, or regular, vigorous exercise. When identifiable by electrocardiogram, LVH may be associated with an increased risk for acute cardiovascular events, such as sudden cardiac death, stroke, and heart attacks. Mild focal areas of coronary artery disease were noted (not further described in the autopsy report), no significant atherosclerosis was noted, and the remainder of the heart evaluation was unremarkable. No other significant natural disease was identified.
The FAA's Bioaeronautical Research Laboratory conducted toxicology testing of specimens from the flight instructor. The testing identified 0.013 gm/dl of ethanol in the kidney, but no ethanol was identified in the muscle tissue. After absorption, ethanol is quickly distributed throughout the body's tissues and fluids fairly uniformly. The distribution pattern parallels the water content and blood supply of each organ. Ethanol may also be produced by postmortem microbial activity in the body.
Student
According to the Kern County Coroner's autopsy report, the student's cause of death was "multiple blunt force trauma," and the manner of death was "accident."
The FAA's Bioaeronautical Research Laboratory conducted toxicology tests on specimens from the student. The results were negative for carbon monoxide and volatiles and positive for salicylate in the urine.
ADDITIONAL INFORMATION
Flight Test Procedures
Review of the BFAP F9 flight card for the accident flight revealed that 10 maneuvers were to be conducted. The first four maneuvers involved unusual attitudes and a stall series that included straight ahead, left, and right turn 1-g stalls with delayed subsequent recoveries from 1 to 3 seconds.
Maneuvers 5 through 8, which included spins, stated the following:
Maneuver 5: Right spin, three turns, flight manual recovery
Maneuver 6: Left spin, three turns, flight manual recovery
Maneuver 7: Right spin, six turns, two turns ailerons neutral, additional two turns left aileron, additional two turns right aileron, flight manual recovery
Maneuver 8: Left spin, six turns, two turns ailerons neutral, additional two turns right aileron, additional two turns left aileron, Flight manual recovery
Maneuvers 9 and 10 included a loop and roll before returning to the airport.
The flight card stated that the stall series and three-turn spin series were to be executed at an altitude of 9,000 ft msl and that the six-turn spin series was to be executed at 10,000 ft msl. In addition, the card noted that all recoveries should be initiated by 7,500 ft msl and that the bailout altitude was 6,000 ft msl.
Video Examination
A GoPro Hero 3 camera, enclosed in a watertight case, was located in the wreckage and subsequently sent to the NTSB Vehicle Recorders Laboratory for review. Examination of the camera revealed that the memory card contained various recordings and had captured video showing the airplane located on the ramp at the departure airport through the time the accident occurred. The camera appeared to have been mounted on the right side of the airplane's canopy and provided a view of the right wing, including the right flap and aileron. Additionally, reflections on the canopy were observed throughout various portions of the recording. The reflections included those of the passenger, who was seated in the right seat and was wearing a green flight suit, and the flight instructor, who was seated in the left seat and was wearing a blue flight suit. Throughout the recordings, some muffled vocal comments, cockpit noises, and muffled engine noises were heard.
The video showed that, about 11 minutes after takeoff, the flight instructor and student conducted a stall, consistent with maneuver 2 on the flight card, and that maneuvers 1 and 3 were not flown. Upon completion of maneuver 2, the airplane entered maneuver 4, and a left 2-revolution spin was performed. About 4 minutes later, the airplane performed maneuver 5, which incorporated a 4-revolution right spin with a normal recovery. About 5 minutes later, the airplane performed a left 4.5-revolution spin, consistent with maneuver 6.
The airplane then entered a right spin, consistent with maneuver 7. As the airplane completed about 21 revolutions, the student reported an altitude of "6,000 ft" followed by another announcement of an altitude of "5,500 [ft]" 1 revolution later. It could not be determined whether the word "bailout" was said after "5,500" was announced. The canopy was opened between revolutions 24 and 25. Reflections within the canopy showed the instructors right arm grabbing the canopy between revolutions 27 and 28, while the student was observed standing while grabbing the upper canopy rail between revolutions 29 and 30. The student subsequently jumped from the right wing between revolutions 33 and 34; little-to-no movement of the flight instructor was observed. At the time of ground impact, the airplane had completed about 34 revolutions.
For further information regarding the captured video, see the Onboard Image Recorder Factual Report in the public docket for this accident.
Spin Procedures
Review of the Pilot's Operating Handbook for the accident make/model airplane, Section 4, "Normal Procedures, Spin Recovery," stated that the following steps were to be taken to recover from a spin:
1. Throttle- IDLE
2. Flaps – Raise (If lowered)
3. Hold control stick back with ailerons neutral
4. Check direction of rotation of spin by external visual reference and the turn indicator needle
5. Apply and maintain full rudder to oppose the direction of spin
6. Pause – One Second
7. Move control stick, with the ailerons neutral, progressively forward until the spin stops
8. Immediately [when] the spin stops, centralize the rudder and fly the aircraft in a straight line, out of the dive with a 3-g pullout.
Warning – A high rotation rate spin may occur if the correct recovery procedure is not followed; particularly if the control column is moved forward, partially, or fully before the application of full anti-spin rudder. Such out of sequence control actions will delay recovery and increase the height loss. If the aircraft has not recovered within 2 (two) complete rotations after application of full anti-spin rudder and fully forward control column, the following procedure may be used to expedite recovery.
1. Check that full ant-spin rudder is applied.
2. Move the control column FULLY AFT – then slowly forward until the spin stops.
3. Centralize the controls and recover to level flight (observing the 'g' limits).
NTSB Identification: WPR15FA021
14 CFR Part 91: General Aviation
Accident occurred Friday, October 24, 2014 in Ridgecrest, CA
Aircraft: SLINGSBY T67M 260, registration: N456FR
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 October 24, 2014, about 0900 Pacific daylight time, a Slingsby T67M-260, N456FR, was substantially damaged when it impacted terrain near Ridgecrest, California. The airplane was registered to L'Avion Inc., Mojave, California, and operated by the National Test Pilot School under the provisions of Title 14 Code of Federal Regulations Part 91. The flight instructor and passenger were fatally injured. Visual meteorological conditions prevailed and no flight plan was filed for the instructional flight. The local flight originated from Mojave Airport (MHV), Mojave, about 0832.
Information provided by representatives from the National Test Pilot School revealed that the flight was part of the Flight Test Engineer training program and that the flight had the primary focus of spin training. Following a loss of radar and radio contact with Air Traffic Control, the wreckage was located by company aircraft.
Examination of the accident site revealed that the airplane impacted open desert terrain about 12 miles south of Ridgecrest. Wreckage debris remained within about 10 feet of the main wreckage. Vegetation, about 12 to 18 inches in height, located immediately to the left and right of the aft area of the fuselage appeared to be undamaged. All major structural components were located at the accident site. The wreckage was recovered to a secure location for further examination.
NTSB Identification: WPR15FA021
14 CFR Part 91: General Aviation
Accident occurred Friday, October 24, 2014 in Ridgecrest, CA
Probable Cause Approval Date: 05/23/2017
Aircraft: SLINGSBY T67M 260, registration: N456FR
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 flight instructor and student, who was receiving instruction as part of a Flight Test Engineer program, departed with the intent of completing a flight card that called for 10 maneuvers, 4 of which included spins for a certain amount of rotations. The program allowed students to fly the airplane if they felt comfortable; however, it did not require that the student fly the airplane. A camera mounted inside the airplane provided a view of the right wing. Review of the recorded video revealed that the flight performed two left spins and one right spin with uneventful recoveries before the accident sequence.
The video showed that, during the accident sequence, the airplane entered a right spin, consistent with a maneuver on the flight card, which called for a six-rotation right spin with aileron inputs before recovery. Throughout the spin sequence, little-to-no aileron input was observed. As the airplane completed about 21 revolutions, the student made an altitude call of "6,000 ft," which was the specified bailout altitude. Shortly after, a callout of "5,500 ft" was made during revolution 22, and the canopy was opened between revolutions 24 and 25. Reflections within the canopy showed the student standing while grabbing the upper canopy rail between revolutions 29 and 30 and subsequently jumping from the right wing between revolutions 33 and 34. At the time of ground impact, the airplane had completed about 34 revolutions. The delayed egress from the airplane below the specified egression altitude and just before impact likely contributed to the student's fatal injuries. Little-to-no movement of the flight instructor was observed on the video; thus it is likely he did not attempt to bailout of the airplane.
Postaccident examination of the airframe and engine revealed no evidence of any preexisting mechanical malfunctions that would have precluded normal operation. In addition, the airplane was found to be within weight-and-balance and center-of-gravity limits. Further, a recent inspection of the airplane's rigging revealed that it was within limits prior to the accident flight. The accident circumstances are consistent with the pilots' failure to recover from a spin; however, the reason for this could not be determined.
Although the flight instructor's toxicology testing detected ethanol in the kidney, the absence of ethanol in the muscle suggests the identified ethanol was likely from postmortem production rather than ingestion. Although the autopsy of the flight instructor identified left ventricular hypertrophy, which is most often associated with hypertension, age, or regular, vigorous exercise and may be associated with an increased risk for acute cardiovascular events, only mild coronary artery disease and no significant atherosclerosis were noted. However, if a cardiovascular event or loss of consciousness from any other cause (such as a seizure or neurogenic syncope) occurred in the few minutes before the flight instructor's death, it would have left no evidence on autopsy.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilots' failure to recover from a spin for reasons that could not be determined based on available information. Contributing to the student's fatal injury was his delayed egress from the airplane below the specified egression altitude.
The National Transportation Safety Board traveled to the scene of this accident.
Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Van Nuys, California
Lycoming Engines; Williamsport, Pennsylvania
Flight Research Inc.; Mojave, California
National Test Pilot School; Mojave, California
Aviation Accident Factual Report - National Transportation Safety Board: https://app.ntsb.gov/pdf
Registered to L'Avion, Inc., Mojave, California
Operated by the National Test Pilot School (NTPS)
http://registry.faa.gov/N456FR
NTSB Identification: WPR15FA021
14 CFR Part 91: General Aviation
Accident occurred Friday, October 24, 2014 in Ridgecrest, CA
Aircraft: SLINGSBY T67M 260, registration: N456FR
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 October 24, 2014, about 0900 Pacific daylight time, a Slingsby T67M-260, N456FR, impacted terrain near Ridgecrest, California. The flight instructor and student were fatally injured, and the airplane sustained substantial damage. The airplane was registered to L'Avion, Inc., Mojave, California, and was being operated by the National Test Pilot School (NTPS) as a 14 Code of Federal Regulations Part 91 instructional flight. Visual meteorological conditions existed near the accident site about the time of the accident, and no flight plan was filed. The local flight originated from Mojave Airport, Mojave, California, about 0832.
NTPS representatives provided information to the National Transportation Safety Board (NTSB) investigator-in-charge (IIC) that indicated that the flight was part of the Flight Test Engineer Training Program, which includes the Basic Flight Awareness Program (BFAP). The purpose of the flight was to perform a series of stalls and spins. After air traffic controllers lost radar and radio contact with the airplane, a search was initiated, and the wreckage was subsequently located by a pilot in a company aircraft. Review of radar data provided by the Federal Aviation Administration (FAA) revealed that the airplane was at an altitude of about 11,800 ft mean sea level (msl) before it began a spin sequence and crashed.
Another flight instructor reported that he had flown with the student 3 days before the accident in a different airplane of the same make and model. The instructor stated that the flight was BFAP Flight 9 (F9) and that the student was flying the airplane during a phase-c stall, which included a 3-second application of full left rudder and full aft control stick inputs. During the maneuver, the airplane did not recover as expected, and the instructor ordered the student to initiate recovery from a spin per the flight manual procedures. Following two more rotations and proper recovery technique by the student, the airplane continued in a left spin. The flight instructor took control of the airplane and applied spin recovery control inputs. The airplane continued to spin an additional two rotations before the instructor applied full opposite rudder and full aft stick, reinitiating the flight manual recovery procedure with the use of more forward stick inputs at a faster rate.
The instructor further reported that, following two additional revolutions, the airplane did not recover, and that he immediately applied full aft stick, full opposite aileron, and "slammed" the control stick full forward in an effort to recover from the spin. The instructor stated that the airplane went into an almost 90°-nose-down attitude and that he recovered about 200 ft above the minimum bailout altitude. The instructor terminated the flight and returned to the departure airport. During the return flight, the instructor noted no evidence of any flight control binding or interference.
The President of NTPS reported that, due to the instructor's difficulty recovering from the spin, the school grounded both of its T67M-260 airplanes to verify their flight control rigging. He reported that the T67M-260 that the student had flown 3 days before the accident was found to be at the maximum rigging limits. Maintenance personnel corrected the rigging, and the airplane was returned to service. He reported that the rigging on the accident airplane was found to be well within limits and that it was subsequently returned to service. He further reported that the accident airplane had been spun hundreds of times by various flight instructors and students with no issues before the accident flight. The NTPS Chief of Operations further reported that, when the accident airplane was returned to service, he had scheduled the student with the accident flight instructor, who had vast experience with spins in propeller-driven aircraft.
PERSONNEL INFORMATION
The flight instructor, age 68, held an airline transport pilot certificate with an airplane multiengine land rating with commercial pilot privileges for airplane single-engine land, rotorcraft helicopter, and instrument helicopter. The flight instructor was issued a second-class airman medical certificate on January 16, 2014, with no limitations. At the time of his most recent medical application, the flight instructor reported that he had accumulated a total flight time of 7,845 hours.
Review of the pilot's logbook with entries dated from December 5, 2012, to October 8, 2014, revealed that his most recent flight review was completed on September 10, 2013, in a Piper PA-34. Between January 1, 2014, and October 8, 2014, the flight instructor had logged a total of 160.3 flight hours, which included 49.9 hours in airplanes, 5.3 hours of which were in the accident make/model airplane, and 94.6 hours in helicopters. Within the 90 days before the accident, the flight instructor had logged 2.3 hours in the accident airplane on October 7 and 8, 2014. Per an entry dated April 15, 2014, the flight instructor flew the accident airplane for 1 hour, with "spins" noted in the comment section. It could not be determined how much total flight time the flight instructor had in the accident make/model airplane. NTPS representatives reported that the flight instructor had previous military flight experience in both fixed-wing aircraft and rotorcraft. As part of his military flight experience, he was a primary flight instructor in T-34C airplanes. In addition, the flight instructor had been employed with NTPS since January 2006.
The student did not hold any flight or medical certificates. However, the student was a student of the Flight Test Engineer training program, which allowed nonpilot-rated students to conduct the specified maneuvers if they felt comfortable doing so. It could not be determined how much actual flight experience the student accumulated while enrolled in the program.
AIRCRAFT INFORMATION
The two-seat, low-wing, fixed-gear airplane, serial number (S/N) 2257, was manufactured in 1996. It was powered by a 260-horsepower Lycoming AEIO-540-D4A5 engine, serial number L-25838-48A, and was equipped with a three-bladed Hoffman adjustable-pitch propeller. Review of airframe and engine logbook records revealed that the most recent annual inspection was completed on August 6, 2014, at an airframe total time of 5,104.8 hours.
Using the reported weights of both occupants and full fuel, the airplane was found to be within weight-and-balance and center-of-gravity limits.
METEOROLOGICAL INFORMATION
At 0855, recorded weather from a station located about 27 miles southwest of the accident site reported calm wind, visibility 10 statute miles, clear sky, temperature 15° C, dew point -4° C, and an altimeter setting of 30.09 inches of mercury.
WRECKAGE AND IMPACT INFORMATION
Representatives of the FAA and NTSB conducted an on-scene examination of the accident site on October 24 and 25, 2014.
Examination of the accident site revealed that the airplane impacted open desert terrain about 12 miles south of Ridgecrest. The airplane came to rest upright oriented on a magnetic heading of about 027° at a GPS elevation of 2,345 ft msl. Wreckage debris, which included plexiglass, rudder, and portions of the engine cowling, remained within about 10 ft of the main wreckage. Vegetation, about 12 to 18 inches high and located immediately to the left and right of the aft area of the fuselage, appeared to be undamaged.
The left wing remained attached to the fuselage. The left aileron remained attached to its respective mounts. The outboard portion of the left flap was separated and located about 1 ft aft of the left wing. The inboard portion of the flap remained attached via the inboard attachment point. The right wing remained attached to the fuselage. The right aileron remained attached to its respective mounts. The outboard portion of the right flap was separated at the outboard attachment mount and remained attached to the inboard portion of the flap. The inboard portion of the flap remained attached via the inboard attachment point.
The empennage remained intact. The left and right horizontal stabilizers remained attached. The left and right elevators remained attached via their respective mounts. The trim tab remained attached via its respective mount. The rudder was separated from the vertical stabilizer at the upper hinge attachment point, and the separated portion of the rudder was located about 1 ft aft of the main wreckage. The bottom portion of the rudder, which included the rudder bellcrank, remained attached to the vertical stabilizer.
Flight control continuity was established from the cockpit controls to all primary control surfaces. No breaks or separations were observed within the entire flight control system.
The fuselage appeared to be intact with displaced portions of the composite structure aft of the cockpit area, consistent with impact-related forces. An additional separation of the fuselage (crack) was observed immediately aft of the seats. Dirt/sand was observed on the right side of the cowling, and it was built up higher than on the wing's left side.
Documentation of the cockpit area revealed that both the left and right seat five-point restraints remained attached to the fuselage attachment points; however, all harnesses were separated from the clasp assembly. The left seat shoulder restraint metal clasp was found partially embedded in the outside portion of the fuselage.
The cabin area remained intact, and the canopy was separated. The aft canopy slide mechanism was located in an "aft" position, consistent with the canopy being in an "open" position. The canopy slide lock was found in the "unlocked" position.
The wreckage was recovered to a secure location for further examination; both wings, horizontal stabilizers, and elevators were removed to facilitate transport of the wreckage. Examination of the recovered wreckage was conducted at the facilities of Air Transport, Phoenix, Arizona, on December 11, 2014, by the NTSB IIC and a representative from Lycoming Engines.
No evidence of binding or restricted travel was observed. The left seat control stick was fractured at the base. The fracture surfaces exhibited signatures consistent with overload separation.
Examination of the recovered engine revealed that all engine accessories remained attached to the engine except for the right magneto, oil filter, vacuum pump, and fuel control servo. The rocker box covers, left magneto, and top spark plugs were removed. The crankshaft was rotated using a hand tool attached to one of the accessory case drive pads. Rotational continuity was established throughout the engine and valve train, and thumb compression was obtained on all six cylinders. Both the left and right magnetos were intact and produced spark on all posts when the magneto drive shafts were rotated using a hand drill.
For further information regarding the airframe and engine examination, see the NTSB Accident Site, Airframe, and Engine Examination Summary Report within the public docket for this accident.
MEDICAL AND PATHOLOGICAL INFORMATION
Flight Instructor
According to the Kern County Coroner's autopsy report, the flight instructor's cause of death was "multiple blunt force trauma," and the manner of death was "accident." Examination of the body identified left ventricular hypertrophy, which is most often associated with hypertension, age, or regular, vigorous exercise. When identifiable by electrocardiogram, LVH may be associated with an increased risk for acute cardiovascular events, such as sudden cardiac death, stroke, and heart attacks. Mild focal areas of coronary artery disease were noted (not further described in the autopsy report), no significant atherosclerosis was noted, and the remainder of the heart evaluation was unremarkable. No other significant natural disease was identified.
The FAA's Bioaeronautical Research Laboratory conducted toxicology testing of specimens from the flight instructor. The testing identified 0.013 gm/dl of ethanol in the kidney, but no ethanol was identified in the muscle tissue. After absorption, ethanol is quickly distributed throughout the body's tissues and fluids fairly uniformly. The distribution pattern parallels the water content and blood supply of each organ. Ethanol may also be produced by postmortem microbial activity in the body.
Student
According to the Kern County Coroner's autopsy report, the student's cause of death was "multiple blunt force trauma," and the manner of death was "accident."
The FAA's Bioaeronautical Research Laboratory conducted toxicology tests on specimens from the student. The results were negative for carbon monoxide and volatiles and positive for salicylate in the urine.
ADDITIONAL INFORMATION
Flight Test Procedures
Review of the BFAP F9 flight card for the accident flight revealed that 10 maneuvers were to be conducted. The first four maneuvers involved unusual attitudes and a stall series that included straight ahead, left, and right turn 1-g stalls with delayed subsequent recoveries from 1 to 3 seconds.
Maneuvers 5 through 8, which included spins, stated the following:
Maneuver 5: Right spin, three turns, flight manual recovery
Maneuver 6: Left spin, three turns, flight manual recovery
Maneuver 7: Right spin, six turns, two turns ailerons neutral, additional two turns left aileron, additional two turns right aileron, flight manual recovery
Maneuver 8: Left spin, six turns, two turns ailerons neutral, additional two turns right aileron, additional two turns left aileron, Flight manual recovery
Maneuvers 9 and 10 included a loop and roll before returning to the airport.
The flight card stated that the stall series and three-turn spin series were to be executed at an altitude of 9,000 ft msl and that the six-turn spin series was to be executed at 10,000 ft msl. In addition, the card noted that all recoveries should be initiated by 7,500 ft msl and that the bailout altitude was 6,000 ft msl.
Video Examination
A GoPro Hero 3 camera, enclosed in a watertight case, was located in the wreckage and subsequently sent to the NTSB Vehicle Recorders Laboratory for review. Examination of the camera revealed that the memory card contained various recordings and had captured video showing the airplane located on the ramp at the departure airport through the time the accident occurred. The camera appeared to have been mounted on the right side of the airplane's canopy and provided a view of the right wing, including the right flap and aileron. Additionally, reflections on the canopy were observed throughout various portions of the recording. The reflections included those of the passenger, who was seated in the right seat and was wearing a green flight suit, and the flight instructor, who was seated in the left seat and was wearing a blue flight suit. Throughout the recordings, some muffled vocal comments, cockpit noises, and muffled engine noises were heard.
The video showed that, about 11 minutes after takeoff, the flight instructor and student conducted a stall, consistent with maneuver 2 on the flight card, and that maneuvers 1 and 3 were not flown. Upon completion of maneuver 2, the airplane entered maneuver 4, and a left 2-revolution spin was performed. About 4 minutes later, the airplane performed maneuver 5, which incorporated a 4-revolution right spin with a normal recovery. About 5 minutes later, the airplane performed a left 4.5-revolution spin, consistent with maneuver 6.
The airplane then entered a right spin, consistent with maneuver 7. As the airplane completed about 21 revolutions, the student reported an altitude of "6,000 ft" followed by another announcement of an altitude of "5,500 [ft]" 1 revolution later. It could not be determined whether the word "bailout" was said after "5,500" was announced. The canopy was opened between revolutions 24 and 25. Reflections within the canopy showed the instructors right arm grabbing the canopy between revolutions 27 and 28, while the student was observed standing while grabbing the upper canopy rail between revolutions 29 and 30. The student subsequently jumped from the right wing between revolutions 33 and 34; little-to-no movement of the flight instructor was observed. At the time of ground impact, the airplane had completed about 34 revolutions.
For further information regarding the captured video, see the Onboard Image Recorder Factual Report in the public docket for this accident.
Spin Procedures
Review of the Pilot's Operating Handbook for the accident make/model airplane, Section 4, "Normal Procedures, Spin Recovery," stated that the following steps were to be taken to recover from a spin:
1. Throttle- IDLE
2. Flaps – Raise (If lowered)
3. Hold control stick back with ailerons neutral
4. Check direction of rotation of spin by external visual reference and the turn indicator needle
5. Apply and maintain full rudder to oppose the direction of spin
6. Pause – One Second
7. Move control stick, with the ailerons neutral, progressively forward until the spin stops
8. Immediately [when] the spin stops, centralize the rudder and fly the aircraft in a straight line, out of the dive with a 3-g pullout.
Warning – A high rotation rate spin may occur if the correct recovery procedure is not followed; particularly if the control column is moved forward, partially, or fully before the application of full anti-spin rudder. Such out of sequence control actions will delay recovery and increase the height loss. If the aircraft has not recovered within 2 (two) complete rotations after application of full anti-spin rudder and fully forward control column, the following procedure may be used to expedite recovery.
1. Check that full ant-spin rudder is applied.
2. Move the control column FULLY AFT – then slowly forward until the spin stops.
3. Centralize the controls and recover to level flight (observing the 'g' limits).
14 CFR Part 91: General Aviation
Accident occurred Friday, October 24, 2014 in Ridgecrest, CA
Aircraft: SLINGSBY T67M 260, registration: N456FR
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 October 24, 2014, about 0900 Pacific daylight time, a Slingsby T67M-260, N456FR, was substantially damaged when it impacted terrain near Ridgecrest, California. The airplane was registered to L'Avion Inc., Mojave, California, and operated by the National Test Pilot School under the provisions of Title 14 Code of Federal Regulations Part 91. The flight instructor and passenger were fatally injured. Visual meteorological conditions prevailed and no flight plan was filed for the instructional flight. The local flight originated from Mojave Airport (MHV), Mojave, about 0832.
Information provided by representatives from the National Test Pilot School revealed that the flight was part of the Flight Test Engineer training program and that the flight had the primary focus of spin training. Following a loss of radar and radio contact with Air Traffic Control, the wreckage was located by company aircraft.
Examination of the accident site revealed that the airplane impacted open desert terrain about 12 miles south of Ridgecrest. Wreckage debris remained within about 10 feet of the main wreckage. Vegetation, about 12 to 18 inches in height, located immediately to the left and right of the aft area of the fuselage appeared to be undamaged. All major structural components were located at the accident site. The wreckage was recovered to a secure location for further examination.
Report of plane crash unfounded, fire chief says
OCONEE COUNTY, SOUTH CAROLINA — Fire Chief Charlie King said a camper called 911 around 4:30 p.m. and told dispatchers they saw a small plane in a dive and a short time later heard an explosion.
King said the crash was reported along a waterway near the Georgia- South Carolina state line.
The area crews were searching is near Cooper Road and Cleveland Pike Road.
King told WYFF News 4, crews searched on land and water for about 90 minutes and never found any evidence of a plane crash.
People living in the search area told search teams, one of the property owners in that area owns a "float" plane to travel between homes and they had seen him in the area prior to the 911 call.
Original article can be found here: http://www.wyff4.com
King said the crash was reported along a waterway near the Georgia- South Carolina state line.
The area crews were searching is near Cooper Road and Cleveland Pike Road.
King told WYFF News 4, crews searched on land and water for about 90 minutes and never found any evidence of a plane crash.
People living in the search area told search teams, one of the property owners in that area owns a "float" plane to travel between homes and they had seen him in the area prior to the 911 call.
Original article can be found here: http://www.wyff4.com
Piper PA-28-180 Archer, N32150: Accident occurred October 10, 2014 near Bend Municipal Airport (KBDN), Deschutes County, Oregon
Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf
Analysis
The private pilot reported that, about 4 to 5 minutes after takeoff for the personal flight and while climbing to 6,000 ft mean sea level (msl), the engine started to "shake and roll," and the rpm reduced from about 2,400 to 1,800 rpm. The pilot then reversed course to return to the airport. The pilot turned on the carburetor heat and enriched the fuel mixture, which did not restore full engine power. The rpm then dropped to between about 1,300 and 1,200, which was insufficient to maintain altitude. As the pilot approached the airport, he realized that the airplane was not going to reach the runway, so he executed an off-airport landing, during which the landing gear and the right wing separated from the fuselage.
A postaccident examination of the engine and fuel system did not reveal any mechanical anomalies or malfunctions that would have precluded normal operation. Weather conditions from the surface to 10,000 ft msl were conducive to the accumulation of moderate-to-severe carburetor icing. Therefore, it is likely that carburetor ice accumulated during the climb, which resulted in a partial loss of engine power. It is likely that the pilot's delayed use of carburetor heat was insufficient to clear the ice before the return to the airport.
Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
A partial loss of engine power due to carburetor icing, which resulted from the pilot's failure to apply carburetor heat after takeoff and during the climb.
Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Hillsboro, Oregon
Aviation Accident Factual 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/N32150
NTSB Identification: WPR15LA008
14 CFR Part 91: General Aviation
Accident occurred Friday, October 10, 2014 in Bend, OR
Aircraft: PIPER PA 28-180, registration: N32150
Injuries: 2 Minor.
NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.
HISTORY OF FLIGHT
On October 10, 2014, at 0715 Pacific daylight time, a Piper PA-28-180, N32150, sustained substantial damage following a partial loss of engine power and subsequent off field landing 1 mile from the Bend Municipal Airport, Bend, Oregon. The private pilot and his passenger received minor injuries. During the landing the right wing separated from the airplane. The airplane was registered to the pilot who operated the airplane under the provisions of 14 Code of Federal Regulations, Part 91. Visual meteorological conditions prevailed for the flight, and no flight plan had been filed. The flight originated from Bend Municipal Airport at 0705.
The pilot reported that 10 minutes after takeoff, while climbing to 6,000 feet mean sea level (msl), the engine started to shake and rattle violently with an associated 2/3 loss of engine power. He turned ON the carburetor heat and richened the fuel mixture which resulted in no improvement of engine power. The pilot reversed course to return to the airport. As he approached the airport it became apparent that he was not going to make the runway, at which point he executed an off field landing. The landing area was flat hard ground populated with large pine trees and boulders. The landing sequence resulted in the landing gear and the right wing being separated from the fuselage.
WRECKAGE AND IMPACT INFORMATION
A Federal Aviation Administration inspector arrived on-scene and examined the airplane. He took a fuel sample from the airplane as the recovery crew defueled the airplane. The fuel sample was straw colored but was chemically tested to be consistent with 100 octane low lead (100LL) aviation gasoline.
On February 18, 2015, the NTSB Investigator-in-Charge (IIC) examined the airplane. The right wing had been sheared off at the wing root by ground impact forces. There was a 24 inch diameter semicircular crush that extended aft into the center of the wing at the leading edge, outboard of the fuel tank, which separated the wing into two pieces. The fuel cap was present on the filler hole, and the fuel tank had a breach located at the outboard leading edge of the tank. Recovery personnel reported that the tank was empty when they arrived on-scene. A hole was cut into the top of the fuel tank to view the fuel port finger screen, which was observed to be clear of any foreign matter or debris.
The left wing had been detached from the airframe by recovery personnel. The wing tip exhibited impact crush damage. The aileron and flaps were present on the trailing edge of the wing. The fuel tank cap was present on the fuel filler port. Recovery personnel stated that they recovered 7 gallons of avgas from this tank during the wreckage recovery. The recovered fluid was examined and was observed to have properties consistent with 100 LL avgas (blue coloration with a petroleum odor). A hole was cut in the top of the fuel tank to view the fuel port finger screen, which was observed to be clear of foreign matter or debris.
Impact damage had fractured the generator housing, and separated it from its forward mount. Impact damage to the air box/filter had pushed it into the carburetor. Carburetor heat control cable was not attached to the carburetor heat butterfly plate actuator arm, but the bolt and nut that attaches the cable to the butterfly plate arm was present. Both throttle and mixture control arms on the carburetor were bent, but the control cables were attached and functional. No damage was observed to any of the cylinders, oil pan, or engine accessories. The oil filter and the date 6/4/2014, was hand written with black ink on the surface.
The top spark plugs were removed. All top plugs were connected to the left hand magneto harness. Cylinder numbers 2, 3, & 4 exhibited normal operating signatures according to the Champion check-a-plug chart. The number 1 top and bottom spark plug exhibited excessive black soot on the electrodes. The propeller was rotated by hand and thumb compression was achieved on all 4 cylinders, and the magneto impulse coupling 'click' could be heard. A bluish fluid was drained from the gascolator. The top spark plug leads were connected to the left hand magneto, the bottom spark plug leads were connected to an electronic ignition.
An external fuel tank was plumbed into the right hand fuel line that feeds the fuel selector. Fuel flow to the carburetor was verified by draining fresh fuel from the gascolator. The airplane battery was connected to the leads, the auxiliary fuel pump was energized for 3 seconds and the fuel primer was pumped 5 times. After numerous attempts, the engine started and was run up to 2,500 rpm. Oil pressure was steady at 80 psi. The engine ran steadily at 2,500 rpm for a couple of minutes, and a magneto check was performed. The electronic ignition rpm drop was about 50 rpm, and the left hand magneto drop was about 200 rpm. The engine idled steady at 1,800 rpm.
METEOROLOGICAL INFORMATION
Weather information obtained from the Bend Municipal Airport Automated Weather Observation System (AWOS-3) for 0715 recorded wind from 160° at 5 knots, 10 statute miles visibility, the sky was clear, temperature was 7°C, dew point was 0°C, and altimeter was 30.14 inHg.
The upper air sounding from MFR (Medford, OR) from 0500 on October 10, 2014, indicated probable carburetor icing from the surface through 6,500 to 7,000 feet msl (mean sea level), then again closer to 10,000 feet msl. These values indicate moderate to severe carburetor icing most of the way up to 10,000 ft. The Salem, OR, upper air sounding supports possible carburetor icing through about 4,000 feet msl.
NTSB Identification: WPR15LA008
14 CFR Part 91: General Aviation
Accident occurred Friday, October 10, 2014 in Bend, OR
Aircraft: PIPER PA 28-180, registration: N32150
Injuries: 2 Minor.
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 may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.
On October 10, 2014, at 0715 Pacific daylight time, a Piper PA-28-180, N32150, sustained substantial damage following a partial loss of engine power and subsequent off field landing 1 mile from the Bend Municipal Airport, Bend, Oregon. The private pilot and his passenger received minor injuries. During the landing the right wing separated from the airplane. The airplane was registered to the pilot who operated the airplane under the provisions of 14 Code of Federal Regulations, Part 91. Visual meteorological conditions prevailed for the flight, and no flight plan had been filed. The flight originated from Bend Municipal Airport at 0705.
The pilot reported that 10 minutes after takeoff, while climbing to 6,000 feet mean sea level (msl), the engine started to shake and rattle violently with an associated 2/3 loss of engine power. The pilot reversed course and attempted to return to the airport. As he approached the airport it became apparent that he was not going to make the runway, at which point he executed an off field landing. The landing area was flat hard ground populated with large pine trees and boulders. The landing sequence resulted in the landing gear and the right wing being separated from the fuselage.
Analysis
The private pilot reported that, about 4 to 5 minutes after takeoff for the personal flight and while climbing to 6,000 ft mean sea level (msl), the engine started to "shake and roll," and the rpm reduced from about 2,400 to 1,800 rpm. The pilot then reversed course to return to the airport. The pilot turned on the carburetor heat and enriched the fuel mixture, which did not restore full engine power. The rpm then dropped to between about 1,300 and 1,200, which was insufficient to maintain altitude. As the pilot approached the airport, he realized that the airplane was not going to reach the runway, so he executed an off-airport landing, during which the landing gear and the right wing separated from the fuselage.
A postaccident examination of the engine and fuel system did not reveal any mechanical anomalies or malfunctions that would have precluded normal operation. Weather conditions from the surface to 10,000 ft msl were conducive to the accumulation of moderate-to-severe carburetor icing. Therefore, it is likely that carburetor ice accumulated during the climb, which resulted in a partial loss of engine power. It is likely that the pilot's delayed use of carburetor heat was insufficient to clear the ice before the return to the airport.
Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
A partial loss of engine power due to carburetor icing, which resulted from the pilot's failure to apply carburetor heat after takeoff and during the climb.
Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Hillsboro, Oregon
Aviation Accident Factual 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/N32150
NTSB Identification: WPR15LA008
14 CFR Part 91: General Aviation
Accident occurred Friday, October 10, 2014 in Bend, OR
Aircraft: PIPER PA 28-180, registration: N32150
Injuries: 2 Minor.
NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.
HISTORY OF FLIGHT
On October 10, 2014, at 0715 Pacific daylight time, a Piper PA-28-180, N32150, sustained substantial damage following a partial loss of engine power and subsequent off field landing 1 mile from the Bend Municipal Airport, Bend, Oregon. The private pilot and his passenger received minor injuries. During the landing the right wing separated from the airplane. The airplane was registered to the pilot who operated the airplane under the provisions of 14 Code of Federal Regulations, Part 91. Visual meteorological conditions prevailed for the flight, and no flight plan had been filed. The flight originated from Bend Municipal Airport at 0705.
The pilot reported that 10 minutes after takeoff, while climbing to 6,000 feet mean sea level (msl), the engine started to shake and rattle violently with an associated 2/3 loss of engine power. He turned ON the carburetor heat and richened the fuel mixture which resulted in no improvement of engine power. The pilot reversed course to return to the airport. As he approached the airport it became apparent that he was not going to make the runway, at which point he executed an off field landing. The landing area was flat hard ground populated with large pine trees and boulders. The landing sequence resulted in the landing gear and the right wing being separated from the fuselage.
WRECKAGE AND IMPACT INFORMATION
A Federal Aviation Administration inspector arrived on-scene and examined the airplane. He took a fuel sample from the airplane as the recovery crew defueled the airplane. The fuel sample was straw colored but was chemically tested to be consistent with 100 octane low lead (100LL) aviation gasoline.
On February 18, 2015, the NTSB Investigator-in-Charge (IIC) examined the airplane. The right wing had been sheared off at the wing root by ground impact forces. There was a 24 inch diameter semicircular crush that extended aft into the center of the wing at the leading edge, outboard of the fuel tank, which separated the wing into two pieces. The fuel cap was present on the filler hole, and the fuel tank had a breach located at the outboard leading edge of the tank. Recovery personnel reported that the tank was empty when they arrived on-scene. A hole was cut into the top of the fuel tank to view the fuel port finger screen, which was observed to be clear of any foreign matter or debris.
The left wing had been detached from the airframe by recovery personnel. The wing tip exhibited impact crush damage. The aileron and flaps were present on the trailing edge of the wing. The fuel tank cap was present on the fuel filler port. Recovery personnel stated that they recovered 7 gallons of avgas from this tank during the wreckage recovery. The recovered fluid was examined and was observed to have properties consistent with 100 LL avgas (blue coloration with a petroleum odor). A hole was cut in the top of the fuel tank to view the fuel port finger screen, which was observed to be clear of foreign matter or debris.
Impact damage had fractured the generator housing, and separated it from its forward mount. Impact damage to the air box/filter had pushed it into the carburetor. Carburetor heat control cable was not attached to the carburetor heat butterfly plate actuator arm, but the bolt and nut that attaches the cable to the butterfly plate arm was present. Both throttle and mixture control arms on the carburetor were bent, but the control cables were attached and functional. No damage was observed to any of the cylinders, oil pan, or engine accessories. The oil filter and the date 6/4/2014, was hand written with black ink on the surface.
The top spark plugs were removed. All top plugs were connected to the left hand magneto harness. Cylinder numbers 2, 3, & 4 exhibited normal operating signatures according to the Champion check-a-plug chart. The number 1 top and bottom spark plug exhibited excessive black soot on the electrodes. The propeller was rotated by hand and thumb compression was achieved on all 4 cylinders, and the magneto impulse coupling 'click' could be heard. A bluish fluid was drained from the gascolator. The top spark plug leads were connected to the left hand magneto, the bottom spark plug leads were connected to an electronic ignition.
An external fuel tank was plumbed into the right hand fuel line that feeds the fuel selector. Fuel flow to the carburetor was verified by draining fresh fuel from the gascolator. The airplane battery was connected to the leads, the auxiliary fuel pump was energized for 3 seconds and the fuel primer was pumped 5 times. After numerous attempts, the engine started and was run up to 2,500 rpm. Oil pressure was steady at 80 psi. The engine ran steadily at 2,500 rpm for a couple of minutes, and a magneto check was performed. The electronic ignition rpm drop was about 50 rpm, and the left hand magneto drop was about 200 rpm. The engine idled steady at 1,800 rpm.
METEOROLOGICAL INFORMATION
Weather information obtained from the Bend Municipal Airport Automated Weather Observation System (AWOS-3) for 0715 recorded wind from 160° at 5 knots, 10 statute miles visibility, the sky was clear, temperature was 7°C, dew point was 0°C, and altimeter was 30.14 inHg.
The upper air sounding from MFR (Medford, OR) from 0500 on October 10, 2014, indicated probable carburetor icing from the surface through 6,500 to 7,000 feet msl (mean sea level), then again closer to 10,000 feet msl. These values indicate moderate to severe carburetor icing most of the way up to 10,000 ft. The Salem, OR, upper air sounding supports possible carburetor icing through about 4,000 feet msl.
NTSB Identification: WPR15LA008
14 CFR Part 91: General Aviation
Accident occurred Friday, October 10, 2014 in Bend, OR
Aircraft: PIPER PA 28-180, registration: N32150
Injuries: 2 Minor.
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 may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.
On October 10, 2014, at 0715 Pacific daylight time, a Piper PA-28-180, N32150, sustained substantial damage following a partial loss of engine power and subsequent off field landing 1 mile from the Bend Municipal Airport, Bend, Oregon. The private pilot and his passenger received minor injuries. During the landing the right wing separated from the airplane. The airplane was registered to the pilot who operated the airplane under the provisions of 14 Code of Federal Regulations, Part 91. Visual meteorological conditions prevailed for the flight, and no flight plan had been filed. The flight originated from Bend Municipal Airport at 0705.
The pilot reported that 10 minutes after takeoff, while climbing to 6,000 feet mean sea level (msl), the engine started to shake and rattle violently with an associated 2/3 loss of engine power. The pilot reversed course and attempted to return to the airport. As he approached the airport it became apparent that he was not going to make the runway, at which point he executed an off field landing. The landing area was flat hard ground populated with large pine trees and boulders. The landing sequence resulted in the landing gear and the right wing being separated from the fuselage.
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