Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Tampa, Florida
Van's Aircraft; Aurora, Oregon
Aviation Accident Factual Report - National Transportation Safety Board: https://app.ntsb.gov/pdf
http://registry.faa.gov/N262WS
Location: Bonita Springs, FL
Accident Number: ERA18FA064
Date & Time: 01/22/2018, 1214 EST
Registration: N262WS
Aircraft: VANS AIRCRAFT INC RV-12
Aircraft Damage: Destroyed
Defining Event: Aircraft structural failure
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal
On January 22, 2018, about 1214 eastern standard time, an experimental light sport Van's Aircraft, Inc., RV-12, N262WS, was destroyed when it collided with terrain near Bonita Springs, Florida. The pilot was fatally injured. The airplane was privately owned and operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. Day, visual meteorological conditions prevailed, and no flight plan was filed for the flight, which originated at Page Field (FMY), Fort Myers, Florida, about 1148 and was destined for Everglades Airpark (X01), Everglades City, Florida.
According to air traffic control (ATC) voice communications and radar data obtained from the Federal Aviation Administration (FAA), at 1146, the pilot contacted the FMY local controller and requested flight following to X01. At 1158, the pilot was instructed to fly runway heading and was cleared for takeoff. At 1200, the FMY controller instructed the pilot to contact departure control. The pilot did not respond. The controller repeated the instructions and the pilot again did not respond. The controller then called the departure controller, who reported that the pilot had not contacted them after departure. The controller called the pilot a third time and he did not respond.
At 1201, the pilot contacted the Southwest Florida International Air Traffic Control Tower east radar controller. The controller directed the pilot to turn right to a heading of 170º and maintain 2,500 ft mean sea level (msl). At 1202, the pilot asked the controller to repeat the instruction. The controller repeated the instruction, and at 1202:03, the pilot responded, "course one two zero stay at twenty-five hundred." The controller responded, "November two six two whiskey sierra I don't have time to talk to you four times per control instruction cause there's a lot going on please listen up…"
At 1203, the pilot climbed the airplane to 2,900 ft and then was instructed to return to 2,500 ft; the pilot acknowledged without using the airplane's call sign. The controller reminded the pilot to use his call sign when responding to instructions. At 1209, the controller instructed the pilot to contact approach control. The pilot responded that he could hear the controller, "but I can't understand you can you say it slower?" At 1210:39, the pilot contacted Fort Myers approach. At 1213:49, the approach controller stated to the pilot, "November two whiskey sierra traffic twelve to one o'clock six miles northeast bound altitude indicated two thousand six hundred." The pilot responded that he was looking for the traffic. Six seconds later, the pilot transmitted, "Mayday, mayday." No additional calls were received from the pilot and radar and radio contact were lost shortly thereafter.
The airplane was equipped with a Dynon FlightDEK D180 wide screen display mounted in the cockpit, which recorded various flight, aircraft systems, and engine data throughout the accident flight. The display was recovered and the data was downloaded by NTSB Vehicle Recorders Laboratory specialists. During the cruise portion of the flight, the indicated airspeed exceeded 108 knots on several occasions, and frequently fluctuated between 108 and 116 knots.
Interpolation of radar and recorded data revealed that the airplane descended out of 2,500 ft at 1210, about the same time that the pilot contacted the departure controller. The airplane continued to descend for about 4 minutes, and the airspeed stayed generally between 108 and 120 knots and engine rpm remained between 5,500 and 5,700 (red line rpm was 5,800). About the time the pilot reported that he was looking for traffic (1213:58), there was a small increase in pitch and the airplane slowed to about 103 knots. Over the next 7 seconds, the airplane pitched down from 5.25º nose low to 44.75º nose low, the right roll increased to 37.5º, and the airspeed increased from 104 to 136 knots; the pilot then made the "mayday" call. The airplane continued to roll right past inverted, and the airspeed increased to 169.25 knots before the end of the recording. During the final 10 seconds of recorded data, the engine speed varied between 4,550 and 5,950 rpm. The elapsed time from the mayday call to the end of the recording was about 8 seconds.
Pilot Information
Certificate: Sport Pilot
Age: 68, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): None
Second Pilot Present:No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Sport Pilot None
Last FAA Medical Exam:
Occupational Pilot: No
Last Flight Review or Equivalent: 01/06/2017
Flight Time: 530 hours (Total, all aircraft), 130 hours (Total, this make and model)
The pilot, age 68, held a sport pilot certificate with airplane single-engine land privileges. According to the FAA, the pilot never held an FAA medical certificate, nor was he required to as a sport pilot.
The pilot's logbook contained entries from February 12, 2015, through January 10, 2017. No flight times were forwarded from a previous logbook. There was an endorsement for a flight review dated January 6, 2017. According to information provided by the pilot's insurer, the pilot reported, as of January 12, 2018, 530 total hours flight experience, including 130 hours in the RV-12, and 10 hours in the preceding 12 months.
Aircraft and Owner/Operator Information
Aircraft Make: VANS AIRCRAFT INC
Registration: N262WS
Model/Series: RV-12 NO SERIES
Aircraft Category: Airplane
Year of Manufacture: 2011
Amateur Built: No
Airworthiness Certificate: Experimental Light Sport
Serial Number: 120262
Landing Gear Type: Tricycle
Seats: 2
Date/Type of Last Inspection: 07/24/2016, Condition
Certified Max Gross Wt.: 1320 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 95 Hours as of last inspection
Engine Manufacturer: Rotax
ELT: C126 installed, activated, did not aid in locating accident
Engine Model/Series: 912 ULS
Registered Owner: WORLD ADVENTURE SERIES INC
Rated Power: 100 hp
Operator: On file
Operating Certificate(s) Held: None
The all-metal, two-place, low-wing, single-engine, experimental light sport airplane incorporated a fixed tricycle landing gear. The airplane was equipped with a Rotax 100-horsepower reciprocating engine, and a Sensenich ground-adjustable composite propeller. The removable wings were built around a main spar that connected to the center section bulkhead. The wings were secured with two removable pins. The airplane was built in 2011 and the pilot purchased it in 2017. The total airframe time was 190.4 hours. A condition inspection was completed on July 24, 2016, at 95.0 hours total time.
The mechanic who performed the 2016 condition inspection continued to perform maintenance on the airplane until about 3 months before the accident. At that time, he was at the pilot's hangar, escorted there by the pilot's wife, to perform another condition inspection. During the inspection, he noted a crack near the trailing edge of the elevator. He was on the phone discussing the crack with Van's Aircraft personnel when local law enforcement officers arrived and demanded that he leave the premises. He complied and did not complete the inspection nor did he make a logbook entry for the work in progress. He did not know why the officers asked him to leave. He attempted to find someone to finish the inspection, but he was unsuccessful.
According to the Pilot's Operating Handbook, the maximum structural cruise speed (Vno) was 108 knots, the caution band was 108 to 136 knots, and the never exceed speed (Vne) was 136 knots.
Meteorological Information and Flight Plan
Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: FMY, 17 ft msl
Distance from Accident Site: 18 Nautical Miles
Observation Time: 1153 EST
Direction from Accident Site: 325°
Lowest Cloud Condition: Clear
Visibility: 8 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 9 knots /
Turbulence Type Forecast/Actual: / None
Wind Direction: 140°
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 30.11 inches Hg
Temperature/Dew Point: 26°C / 18°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Fort Myers, FL (FMY)
Type of Flight Plan Filed: None
Destination: Everglades City, FL (X01)
Type of Clearance: VFR Flight Following
Departure Time: 1148 EST
Type of Airspace:
FMY was located about 18 nautical miles (nm) northwest of the accident site. The FMY weather at 1153 included wind from 140º at 9 knots, 8 statute miles visibility, clear sky, temperature 26°C, dew point 18°C, and altimeter setting of 30.11 inches of mercury.
Wreckage and Impact Information
Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries:N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 26.338611, -81.663611 (est)
The airplane impacted a forested area about 33 nm northwest of X01. There was no fire. The wreckage debris field was oriented in a south-to-southwest direction and measured about 715 ft long and about 100 ft wide. All components of the airplane were accounted within the wreckage debris field.
The first piece of wreckage found along the debris path was the left wing. Adjacent to the left wing were fragments of the cockpit canopy. The left wing was located about 670 ft north-northeast of the main wreckage. The flaperon separated into three sections. The inboard section remained attached to the wing. The center and outboard sections were found in close proximity to each other, about 410 ft south-southeast of the left wing. The main wing spar was fractured at the wing root. The spar was bent in an upward direction at the area of fracture. All fracture surfaces of the left wing spar exhibited characteristics of overload. No areas of corrosion were found on or near the fracture surfaces.
The main wreckage consisted of the fuselage, the inboard half of the right wing, and the empennage. These sections came to rest against trees and were highly fragmented. The engine and propeller were separated and found within the fuselage debris. The empennage was adjacent to the fuselage and the vertical stabilizer was still partially attached. The rudder was separated and found adjacent to the vertical stabilizer.
The outboard section of the right wing was found about 55 ft northeast of the fuselage. The aft section exhibited impact signatures consistent with tree contact.
The right stabilator was impact-separated and found about 137 ft northeast of the main wreckage. The left stabilator was impact-separated and found about 83 ft northeast of the main wreckage. The painted surfaces of the right stabilator exhibited brown transfer marks consistent with tree impact.
The wreckage was recovered to a storage facility for additional examination.
Flight control continuity was confirmed from all flight control surfaces to the cockpit controls. All separations and fractures to cables and control rods exhibited overload signatures or were cut by recovery personnel. The flap handle was found in the retracted position.
The autopilot pitch servo was located intact in its mount beneath the right seat pan. The servo arm remained connected to the control column, with no deformation of bolts or rod end bearings at either the servo or the control column attach points, and the servo rod was undamaged along its entire length. The servo linkage was disconnected from the control column, and the pitch servo moved freely in rotation. The shear pin on the servo was intact. All associated wiring was examined for fraying or rubbing, and for loose connections. None were found.
A single, 20-gallon fuel tank was installed. The fuel shutoff handle/valve assembly was separated during the impact sequence and a pre-accident position could not be determined. The fuel tank was breached and no fuel was present. All recovered fuel lines were clear and unobstructed. Fuel tank filler cap was in place and secure. The filler neck and sheet metal surrounding the filler neck were separated during the impact sequence. The fuel pump/strainer was opened for examination. There was no fuel in the bowl; however, there was an odor of fuel on the filter. A small amount of organic matter, identified as a fragment of pine straw, was found inside the bowl.
The engine was examined at the wreckage recovery facility. Both carburetors separated from the engine during the impact sequence. One carburetor was impact-damaged and its fuel bowl was separated and found loose in the wreckage; it was dry and clean inside. The floats were missing. The other carburetor's fuel bowl was intact and secure; when removed, it contained no fuel and was clean and dry. The composite floats were intact. The engine-driven fuel pump was separated from the engine due to impact forces. The pumping mechanism operated when the pump actuator was pushed in manually. No fuel pumped from the unit when actuated. The Nos. 2 and 4 cylinder valve covers exhibited impact damage; the No. 4 cover was broken open from impact forces, exposing the internal components. The four top spark plugs were removed for examination. The electrodes were normal in wear and color when compared to a Champion Check-A-Plug chart. The engine contained an undetermined amount of oil. Due to impact damage, the engine could not be rotated manually and internal continuity could not be established.
The propeller separated from the engine with the splined shaft still attached to the propeller hub. One composite blade was separated at the hub; the other remained mostly intact and the tip was separated.
The pilot was wearing a five-point harness. The anchors were separated from the cockpit structure during the impact sequence. The buckle and clips were found connected and operated normally. The seat and harness were found outside the area of main wreckage, about 30 ft south of the fuselage.
Medical And Pathological Information
The Office of the State of Florida, District 21 Medical Examiner performed the autopsy of the pilot. The cause of death was multiple blunt force injuries. The heart was enlarged and thickened; it weighed about 60 grams more than that of an average man of his weight. There was significant coronary artery disease with about 50% to 75% narrowing of both the left main and left anterior descending coronary arteries.
The FAA Forensic Sciences Laboratory performed toxicology testing on specimens from the pilot. Testing was negative for carbon monoxide and ethanol. Naproxen was identified in the urine. Atenolol was identified in the liver. Citalopram, its metabolite N-desmethylcitalopram, mirtazapine, and trazodone were detected in cavity blood and in the urine.
Naproxen is an analgesic available over-the-counter or by prescription, often with the names Aleve® and Naprosyn®. Atenolol is a blood pressure medication that may also be used to reduce the risk of recurrent heart attacks. Neither of these are considered impairing.
Citalopram is an antidepressant often sold under the name Celexa® that carries a precaution for patients that it impairs mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery). It has not been shown to degrade performance in psychological testing experiments using healthy volunteers.
Mirtazapine is another prescription antidepressant commonly marketed with the name Remeron®. It is well known to cause somnolence (sleepiness) in the majority of people using it and carries the precaution, "Mirtazapine may impair judgment, thinking and particularly, motor skills, because of its prominent sedative effect. The drowsiness associated with mirtazapine use may impair a patient's ability to drive, use machines, or perform tasks that require alertness. Thus, patients should be cautioned about engaging in hazardous activities until they are reasonably certain that mirtazapine therapy does not adversely affect their ability to engage in such activities."
Trazodone is another antidepressant that is sedating enough that it is often prescribed as a sleep aid. It carries this information for prescribers: "Antidepressants may impair the mental and/or physical ability required for the performance of potentially hazardous tasks, such as operating an automobile or machinery; the patient should be cautioned accordingly. Trazodone hydrochloride may enhance the response to alcohol, barbiturates, and other central nervous system depressants."
Major depression itself is associated with significant cognitive degradation, particularly in executive functioning. The cognitive degradation may not improve even with remission of the depressed episode, and patients with severe disease are more significantly affected than those with fewer symptoms or episodes. Thus, depression is a disqualifying condition for pilot medical certification. According to the Guide for Aviation Medical Examiners, an aviation medical examiner should not issue a medical certificate to a depressed pilot. The FAA will consider a special issuance of a medical certificate for depression after six months of treatment if the applicant is clinically stable on one of four approved medications.
Records from the pilot's usual source of care, the Veterans Administration, for the period between January 2015 and the accident date were obtained and reviewed. The records documented that the pilot had hypertension, high cholesterol, obstructive sleep apnea, neurogenic bladder, cataracts, peripheral neuropathy, depression, and post-traumatic stress disorder (PTSD). At the time of his last annual exam (March 2017), he was prescribed atenolol and lisinopril to treat his blood pressure, simvastatin for his cholesterol, use of a continuous positive airway pressure (CPAP) machine for his sleep apnea, and citalopram and trazodone for his psychiatric disease.
Records indicated that the pilot complained of worsening symptoms from PTSD, including nightmares and intrusive thoughts, during the end of 2016 and early 2017. This was apparently brought on by legal issues. The underlying issue was that the pilot had been discovered misrepresenting his military service, which had been revealed on the internet by a group he considered "terrorists." The pilot was facing charges for repeatedly breaking the conditions of a restraining order regarding threatening the wife of the individual who revealed his misrepresentation. The pilot's wife told investigators that she was unaware that her husband was being treated for mental health issues.
Daniel A. Bernath, came to the military community’s attention when someone noticed that he had declared himself to be a Chief Petty Officer in the Navy, claiming that he had been honorarily promoted by the National Association of Naval Photographers (NANP) to that rank. The NANP replied that they never bestowed that rank on anyone in their organization – that only the Master Chief Petty Officer of the Navy can bestow that honor.
Location: Bonita Springs, FL
Accident Number: ERA18FA064
Date & Time: 01/22/2018, 1214 EST
Registration: N262WS
Aircraft: VANS AIRCRAFT INC RV-12
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal
On January 22, 2018, about 1214 eastern standard time, a Van's Aircraft Inc . RV-12, N262WS, was destroyed when it collided with terrain near Bonita Springs, Florida. The sport pilot was fatally injured. The special light sport airplane was registered to a corporation and was operated by the pilot under the provisions of Title 14 Code of Federal Regulations part 91. Day, visual meteorological conditions prevailed, and no flight plan was filed for the personal flight. The flight originated at Page Field (FMY), Fort Myers, Florida about 1200 and was destined for Everglades Airpark (X01), Everglades City, Florida.
According to preliminary air traffic control (ATC) voice communication and radar data obtained from the Federal Aviation Administration (FAA), the flight was en route from FMY to X01. The pilot was receiving flight following services from ATC. While on a southeasterly heading and at 2,500 ft mean sea level, the pilot was advised of traffic in his vicinity. The pilot acknowledged, and shortly after this transmission he stated, "mayday, mayday." No additional calls were received from the pilot and radar and radio contact were lost.
The airplane crashed in a forested area, about 18 nautical miles southeast of FMY. There was no fire. The wreckage path was oriented south-southwest and was about 750 ft in length. All components of the airplane were accounted for at the accident site. Flight control continuity was confirmed from all flight control surfaces to the cockpit controls.
The pilot held a sport pilot certificate with an airplane single engine land rating. According to the FAA, he did not possess an FAA medical certificate, nor was one required to operate as a sport pilot.
The low-wing, single-engine, two-seat airplane incorporated a fixed, tricycle landing gear. The airplane was equipped with a Rotax 912-ULS 100-horsepower reciprocating engine. The engine was fitted with a Sensenich fixed-pitch composite propeller. The airplane was built in 2011. According to the airplane maintenance records, a condition inspection was completed on July 24, 2016, at 95 hours total time.
Aircraft and Owner/Operator Information
Aircraft Manufacturer: VANS AIRCRAFT INC
Registration: N262WS
Model/Series: RV-12 NO SERIES
Aircraft Category: Airplane
Amateur Built: No
Operator: On file
Operating Certificate(s) Held: None
Meteorological Information and Flight Plan
Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: FMY, 17 ft msl
Observation Time: 1153 EST
Distance from Accident Site: 18 Nautical Miles
Temperature/Dew Point: 26°C / 18°C
Lowest Cloud Condition: Clear
Wind Speed/Gusts, Direction: 9 knots, 140°
Lowest Ceiling: None
Visibility: 8 Miles
Altimeter Setting: 30.11 inches Hg
Type of Flight Plan Filed: None
Departure Point: Fort Myers, FL (FMY)
Destination: Everglades City, FL (X01)
Wreckage and Impact Information
Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 26.338611, -81.663611 (est)
Daniel Alan Bernath, age 68, of Ft. Meyers passed away on January 22, 2018. Harvey-Engelhardt Funeral and Cremation Services are handling the arrangements.
This ain't Hell, but you can see it from here: http://thisainthell.us
Pilots of America: https://www.pilotsofamerica.com
BONITA SPRINGS, Fla. - BONITA SPRINGS, Fla. -- A plane crash that led to one person dead was on its way from Page Field to Everglades City. Audio obtained by Fox 4, shows the conversation between an air control supervisor growing increasingly frustrated with the pilot, moments before take off.
Lee County Sheriff Deputies were informed a small plane was observed low flying, near the Bonita Springs National Golf Course. The plane landed in the woods, where the site was "estimated to have approximately 250 plus feet of debris," according to the police report.
Prior to the plane taking off, conversations between the pilot and Page Field air control with what sounds like the pilot's lack of understanding. Below is a transcript of part of the conversation:
Controller: "Number 262, with sierra, I don't have time to talk to you four times for control instructions because there's a lot going on. Please listen up. Trying adding one, seven, zero, maintain VFR two thousand five hundred, over."
Pilot: "One, seven, uh, say two thousand five hundred."
Controller: "I need a call sign with control instruction, please. To, with sierra, verify one-seven-zero heading to two thousand five hundred."
Pilot: "Two, six, two, with sierra. Two, five, zero, zero at one seven."
Controller: "Alright you're not saying anything correctly."
LCSO has not released the name of the victim. The National Transportation Safety Board will release an official cause of the crash.
Story and video: https://www.fox4now.com
Daniel A. Bernath
The picture above of Mister Bernath was on his VFW Posts’ website (that Mr. Bernath made for them). A reverse search on the photo turned up the portrait of Photographer Mate 1st Class John Sheppard. Bernath, who had been accused years earlier of claiming some of Sheppard’s photos for himself, photoshopped his head onto PH1 Sheppard’s portrait and added a rocker to his rank. Bernath also appropriated the badges and medals of PH1 Sheppard. Including the Navy Aircrew Wings, the Navy Expeditionary Medal, and the Navy Good Conduct Medal along with hash marks on his sleeve for twenty years of service – none of which appear in Bernath’s records.
The Bonita Springs plane crash on Monday that took Daniel Bernath’s life wasn’t his first crash according to a report from the National Transportation Safety Board.
Bernath crashed a small plane in 2013 in Oregon after running out of fuel, according to a report from the National Transportation Safety Board.
Documents show that Bernath tried to sue the plane company for not warning about what would happen if the plane was low on fuel, according to documents.
“I knew he crashed, but he never even really talked about it with me,” said Melanie Diferdinando, Bernath’s daughter. She says Bernath was a registered sport pilot and started flying in 2011.
“Mayday Mayday,” said Bernath right before the plane crashed in a wooded area near Bonita National Golf Club. The previous recorded conversation between Bernath and air traffic control was described as “odd” by flying experts.
Following his 2013 plane crash, he made some accusations including calling the American Legion domestic terrorists, according to court documents.
Several online pilot forums show he was under attack for his lack of flying expertise. Bernath was also under fire for claiming military honors he did not earn. Bernath himself admitted to having suicidal thoughts and taking prescription medications on these forums.
To get a sport pilot license you are not required to provide a medical certificate, according to a flying expert.
His daughter chose not to comment on these accusations but said the information paints him in a bad light.
“This plane crash was just shocking. It really kind of threw everyone for a loop,” Diferdinando said. “I feel he’s not that man, he was a good person and he was a good father and a good grandfather.”
This crash is still under investigation.
Story and video: https://www.winknews.com
Police identified the man who died in a plane crash on Monday.
Daniel A. Bernath, 68, was piloting the plane and died when it crashed along Bonita Beach Road.
Bernath's plane was headed to Immokalee. He took off from Page Field in Fort Myers
Bernath lived in the Tanglewood neighborhood in Fort Myers.
He was arrested in Virginia Dec. 2016 on multiple charges of stalking and violating a protective order.
Online records show Bernath pleaded guilty to two of those charges just last week, on Jan. 19th. He was sentenced to one year in jail and two years probation.
The Lee County Sheriff's Office said about 13 minutes after takeoff from Page Field, the plane radioed in a mayday call. The crash happened near the Bonita National Golf Course.
Crews searched the "heavily wooded" area where the plane crashed. Forestry services are helping assist in the search.
Federal investigators started searching the area Tuesday. The debris field is scattered over a 250-foot area.
Denise Wessman was golfing and saw the plane go down.
"We heard something going through the trees, so branches were breaking and then there was a thud," Wessman said. "I didn't know what it was, I thought it was maybe a small remote control plane or something like that."
Wessman was out on the golf course with three others.
"We were about to putt and other the tree line, I saw debris right over the tree line and we heard something going through the trees and a thud," Wessman described. "I said we better call 911, so I went to the cart and got my phone."
The cause of the crash is under investigation.
Story, video and photo: http://www.nbc-2.com
Lawsuit: https://dms.ntsb.gov
Case No. 3’13-cv-1778
Daniel A. Bernath, an individual, and as assignee of Oregon Trail Trust vs. Flight Design USA, James Scheibner, Flight Design GmbH, Hillsdale Aero, Inc., and Does 1 through 10 Defendants.
Complaint for Damages
(1) negligence per se;
(2) negligence;
(3) breach of contract;
(4) products liability;
(5) breach of express warranty;
(6) breach of implied warranty of fitness for a particular purpose;
(7) breach of implied warranty of merchantability;
(8) negligent misrepresentation;
(9) breach of express warranty under ORS Chapter 72;
(10) fraud;
(11) unfair business practices; Punitive damage and attorney fee request.
Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms
The National Transportation Safety Board did not travel to the scene of this accident.
Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Portland, Oreland
Bundesstelle für Flugunfalluntersuchung (BFU); Braunschweig,
Rotech Flight Safety; Vernon,
Flight Design; Woodstock, Connecticut
Flight Design USA; Woodstock, Connecticut
Location: Sisters, OR
Accident Number: WPR13LA396
Date & Time: 09/01/2013, 1800 PDT
Registration: N102HA
Aircraft: FLIGHT DESIGN GMBH CTSW
Aircraft Damage: Substantial
Defining Event: Fuel exhaustion
Injuries: 1 None
Flight Conducted Under: Part 91: General Aviation - Personal
Analysis
The sport pilot was conducting a cross-country flight in the light-sport airplane, and he reported that he encountered strong headwinds during the flight. Concerned that the airplane’s fuel level may be low, he landed at a private airstrip a few miles before his intended destination. He checked the fuel levels and estimated that there was enough fuel for about 30 minutes of flight. He chose to depart, and a few minutes after takeoff, the engine lost all power. He performed a forced landing into a field just short of the destination airport. The airplane sustained substantial damage during the accident sequence, and the pilot was not injured. Immediately following the accident, the pilot reported that the airplane did not have any mechanical malfunctions and that it ran out of fuel. Postaccident examination did not reveal any evidence of a preimpact engine malfunction or failure. Both fuel tanks were found intact and did not appear to be breached. The airplane’s fuel system appeared to meet the light-sport airplane industry design standards for usable fuel, which are similar to the Federal Aviation Administration standards for certified aircraft.
The pilot did not respond directly to multiple requests from the National Transportation Safety Board investigator-in-charge to answer questions regarding the specific accident circumstances. Therefore, the accident conditions could not be fully established. However, the pilot did provide multiple written declarations regarding the quantity of fuel on board at the time of departure from the private airstrip; these reports stated that between 3 and 4.5 gallons of fuel were in the right tank and that no fuel was in the left tank. However, only 1 gallon of fuel was recovered from the right wing tank, and the left tank was found empty, which was well below the Federal Aviation Regulations (FARs) minimum fuel requirements for flight, which state that “no person may begin a flight under visual flight rules conditions unless there is enough fuel to fly to the first point of intended landing and…to fly after that for at least 30 minutes of flight.” Regardless of the pilot’s written estimates of the fuel onboard, as noted previously, in his initial statement, he indicated that the airplane only had about enough fuel remaining for 30 minutes of flight, which was still not enough fuel to meet the FARs minimum fuel requirements, and, therefore, his decision to take off at that time was improper.
The design of the airplane’s wing resulted in both the fuel sight gauge and the dipstick being prone to significantly misrepresenting the actual fuel quantity when the airplane was not level. Therefore, it is possible that the pilot misinterpreted the actual fuel quantity before takeoff. In addition, he exhibited poor decision-making by failing to land earlier in the flight for fuel even though he overflew at least four airports that had fueling facilities. The pilot appeared to have accrued almost 300 hours of flight experience in the airplane since he purchased it about 2 1/2 years earlier. Therefore, he should have had adequate knowledge about its systems and performance capabilities and known that the dipstick and sight gauge were prone to errors and that the airplane would need more fuel to complete the flight.
A similar accident in the United Kingdom (UK) resulted in the airplane’s UK type certificate holder issuing a service bulletin (SB) that recommended that both sight gauges show fuel in flight and that a landing be performed if any gauge reads empty. The SB also warned that, with one tank empty, the flight can continue provided no turbulence is encountered and the airplane is not flown in a sideslip condition such that fuel moves away from the tank outlet. The airplane’s US distributor has not issued an SB regarding flight with one fuel tank empty, and this issue is not addressed in any placards or aircraft operation manuals; therefore, it is possible that the pilot did not realize the limitations of flying the airplane with one fuel tank empty.
Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's inadequate preflight fuel planning and poor decision-making, which resulted in fuel exhaustion and the subsequent loss of engine power. Contributing to the accident was the lack of documentation describing the limitations of the airplane’s fuel system.
Findings
Aircraft
Fuel - Fluid level (Cause)
Personnel issues
Fuel planning - Pilot (Cause)
Decision making/judgment - Pilot (Cause)
Organizational issues
Design of document/info - Manufacturer
Factual Information
HISTORY OF FLIGHT
On September 1, 2013, about 1800 Pacific daylight time, a Flight Design CTSW, N102HA, lost engine power and landed about 1/2 mile short of its intended destination, Sisters Eagle Air Airport, Sisters, Oregon. The light sport airplane was registered to, and operated by, the pilot under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The airplane sustained substantial damage during the accident sequence, and the sport pilot was not injured. The personal flight departed Whippet Field Airport, Sisters, at an unknown time. Visual meteorological conditions prevailed, and no flight plan had been filed.
The pilot provided a verbal statement to a deputy of the Deschutes County Sheriff's Office following the accident. He reported that earlier in the day he departed from Coeur d'Alene, Idaho, en route to Sacramento, California, and that he encountered strong headwinds and low clouds during the flight. Subsequently he landed at Whippet Field, a private dirt airstrip approximately 5 miles east of Sisters Eagle Air Airport to check the airplane's fuel levels. Estimating that he had sufficient fuel for approximately 30 more minutes of flight, he departed. As he approached Sisters Eagle Airport the engine "sputtered" and then stopped producing power. He stated that the engine then started again, but then stopped. The airplane then struck soft dirt, and according to the pilot, it did not crash, but encountered an, "Off runway landing." He stated that the airplane did not have any mechanical problems, and that it ran out of fuel. He further reported that he was renting the airplane, that it was owned by "World Adventure Series," and that the purpose of the flight was to transport a dog to its new owner in California. In a subsequent correspondence with the NTSB investigator-in-charge (IIC) he listed himself as the airplane's owner.
Subsequent examination revealed that the airplane had sustained substantial damage to the firewall, forward cabin structure, and lower right fuselage.
The pilot did not submit a Pilot/Operator Aircraft Accident Report (NTSB Form 6120.1), or respond to multiple requests from the IIC for a phone interview.
In a subsequent correspondence, the pilot's attorney stated that during the flight the pilot encountered strong westerly headwinds, and was having trouble with bright sun in his eyes, and as a result he experienced difficulty reading the instruments, especially the fuel gauge.
The NTSB IIC requested via email that the pilot answer a series of questions further explaining the accident circumstances. His attorney responded, stating that the pilot had elected to deny the request, asking instead to refer to the circumstances described in the complaint the pilot had filed for damages against Flight Design USA, et al, in the U.S. District Court.
PERSONNEL INFORMATION
The pilot held a sport pilot certificate; as such he was limited to flying during the hours of daylight. The certificate was issued on November 27, 2011.
AIRPLANE INFORMATION
The airplane was manufactured in 2007 by Flight Design GmbH, and imported into the United States that year. The pilot purchased the airplane from Flight Design in August 2010, and then transferred ownership to the current owner (a trust located at his home address) in April 2011. According to documentation provided by Flight Design, up until the pilot purchased the airplane in 2010, it had been a demonstration airplane and had accrued a total flight time of about 88 hours. The Hobbs hour meter indicated 382.9 hours at the accident site.
The airplane was powered by a Rotax 912ULS series engine, equipped with a Neuform 2-blade composite propeller. The airplane was equipped with a BRS Aerospace emergency parachute recovery system, which had not been activated during the accident. The most recent documented inspection occurred on November 10, 2012, and was for a condition inspection. At that time, both the airframe and engine had accrued a total flight time of 348.9 hours.
METEOROLOGICAL INFORMATION
Aviation weather observation stations positioned along the route of flight reported similar weather conditions consisting of clear skies, visibility of 10 miles or greater, and light winds.
The closest National Weather Service weather observation to the accident site was from Roberts Field Airport, Redmond, Oregon, located approximately 17 miles east of the accident site at an elevation of 3,080 feet. The airport had an Automated Surface Observation System, which at 1756 reported wind from 330 degrees at 6 knots, clear skies, and visibility of 10 miles. The next observation at 1856 indicated clear skies but with wind from 310 degrees at 11 knots gusting to 18.
The NWS had no advisories current for the route for any Instrument Flight Rules or mountain obscuration conditions, thunderstorms, icing, or any significant turbulence at the time of any preflight weather briefing prior to departure.
The winds aloft forecast for the region indicated winds at 6,000 feet out of the west-southwest with velocities between 9 and 16 knots. At 9,000 feet, the winds were generally out of the southwest, with velocities of between 12 and 31 knots.
According to the U.S. Naval Observatory, Astronomical Applications Department, the computed sunset occurred in Redmond, at 1940, with civil twilight ending at 2010. At 1810, the sun was 15.6 degrees above the horizon at an azimuth of 265 degrees.
TESTS AND RESEARCH
Both wings were removed from the airplane, which was then recovered from the accident site, and examined on February 4, 2014, by the NTSB IIC, and representatives from the FAA, Rotax Aircraft Engines, and Flight Design USA. As the state of manufacture, the German Federal Bureau of Aircraft Accident Investigations (BFU) assigned a non-traveling accredited representative.
The fuel system was examined and was found to be free of obstructions. Both fuel tanks were intact and did not appear to be breached. The fuel caps were in place, and both cap gaskets were intact and pliable, with the cap vents facing the correct direction. The fuel tanks were inspected internally and no debris, contamination, or de-bonding was observed.
Examination of photographs taken at the accident site revealed a circular area of dust surrounding the right wing filler cap, along with a fluid-like streak of dust emanating from the fuel cap and moving aft. Remnants of these signatures were still present during the examination. The photos indicated that the airplane came to rest right-wing-low due to the collapse of the right main landing gear during the impact sequence. The direction of the fuel stain signatures were consistent with a prior tank overfill event, rather than fuel leaking from the tank post-accident.
There was no evidence of pre-impact engine malfunction or failure, and following completion of the examination, the engine was started and operated appropriately at various speeds. A complete examination report is contained within the public docket.
Fuel System Design
The CTSW airplane is equipped with two integral wing tanks, each with a capacity of 17 gallons (16.5 useable). The tanks are 57 inches long by 15 inches wide, extending from the wing root, and positioned forward of the main spar. Fuel quantity is gauged visually within the cabin through a sight-tube located at each wing root rib. Both wings have a dihedral angle of 2 degrees, and a rigid pickup tube with an integral strainer is located at the tank floor at each wing root. Each tank contains a single baffle (anti-sloshing rib) located approximately 21 inches from the root. Fuel passes through the baffle via a series of holes at the leading edge, upper spar cap, and when the fuel quantity is low, through a series of 5 and 8 millimeter holes adjacent to the tank floor. The fuel tanks are vented through vented fuel caps located on the upper outboard surface of the wings. A calibrated dipstick with separate left and right tank increments is utilized to check the fuel quantity when on the ground.
Fuel is fed by gravity down two fuel lines in the cabins A-columns; according to the CTSW Maintenance and Inspection Procedures Manual, the lines in the A-columns are of larger volume, "to maintain fuel flow also in sideslip conditions with low fuel for a certain time". The two lines are connected at a T-fitting located on the engine side of the firewall. From the T-fitting, fuel is routed back into the cabin, and through a fuel shutoff valve (on/off only) and fuel filter. The fuel is then routed back through the firewall to the gascolator located adjacent to the lower section of the engine mount, and then onwards to an engine-driven fuel pump.
The design allows fuel to be fed from both tanks simultaneously, and there is no provision for the pilot to make a fuel tank selection.
Fuel System Testing
Both wings were reattached to the fuselage, along with their respective fuel line fittings. The airplane was leveled both laterally and longitudinally and fuel (totaling 3.5 gallons per side), was incrementally added to each tank while simultaneously recording the levels utilizing both the cabin sight gauge, and the Flight Design fuel quantity dipstick found in the airplane.
The dipstick quantity generally matched the tank quantity. The sight gauges, although prone to parallax error, were accurate to within 1 gallon. However, it was noted that small changes of the airplane's bank angle resulted in large fluctuations in the quantity observed at the sight gauge; specifically, with 3.5 gallons of fuel in the tanks, lowering the right wing 2 degrees resulted in the indicated fuel dropping to the 1-gallon level. Similar but reversed (due to the location of the cap at the tip of the tank) values were observed at the dipstick for various bank angles.
Recovered Fuel Quantity
Recovery personnel reported draining about 1.5 gallons from the right wing tank during the recovery, and stated that the left wing tank was empty. They did not observe fuel issue from either of the wing tank fuel lines during removal of the wings from the airframe. When questioned about the method utilized to gauge the recovered fuel quantity, a recovery technician stated that it filled the lower 3 inches of a 5-gallon bucket. The examination group then filled the same bucket with fuel to the 3-inch level and measured the quantity with a calibrated beaker, resulting in an observed total of 1 gallon and 4 ounces (1.03 gallons).
Fuel Records
Two fueling facilities were located at Coeur d'Alene Airport, and both were capable of supplying 100 low-lead aviation gasoline. Both facilities reviewed their fueling records for the one week period leading up to the accident, and neither could locate records for the pilot or airplane during that period.
Whippet Field Airport was a private field comprised of a single turf airstrip. It did not have provisions for refueling. The airstrip was along the presumed route of flight, and about 5.5 miles east of Sisters Eagle Air Airport.
The last 170 miles of the route of flight (assuming a heading of 230 degrees magnetic) would have passed within 10 miles of 17 airports, 4 of which had refueling facilities.
ADDITIONAL INFORMATION
Pilots Statement Regarding Fuel Quantities
The pilot and his attorney provided three separate submissions containing references to the fuel quantity onboard the airplane when it departed Whippet Field Airport. The first included a statement written by the pilot, and signed presumably by a witness reporting that the witness observed the pilot check the fuel quantity utilizing the fuel gauge dipstick, and that the right fuel tank contained 3 gallons of fuel (a separate notation of "over 3 gallons" was written in a different typeface at the end of the sentence). A second document written by the pilot's attorney stated that 4.5 gallons of fuel was present in the right tank. A subsequent email sent by the pilot stated that the airplane was carrying between 3 to 4 gallons of fuel in the right tank. All documents reported that the left tank was empty.
CTSW Operating instructions
According to the CTSW Airplane Operating Instructions current for the airplane at the time of the accident, the airplane's fuel capacity was 17 US gallons per tank, 16.5 of which is usable. The manual states that fuel is gravity fed, and that the fuel valve has two positions, either "on" or "off".
The engine can operate on both 100 low-lead aviation gasoline as well as premium automotive unleaded gasoline which meets American Society for Testing and Materials (ASTM) D 4814 specifications, with a minimum anti knock index of 91. Fuel consumption at takeoff and "75% continuous performance" was 7.1 and 4.9 gallons per hour, respectively.
Flight Design discontinued production of the CTSW model in 2007, replacing it with a similar variant, the CTLS. The fuel system remained largely the same with the exception that a return flow flapper valve was included on the fuel tank anti-sloshing rib. Additionally the tanks were interconnected with a vent line, and each tank also vented to its respective wingtip. The CTLS Airplane Operating Instructions, Normal Operating Procedures (Cruise) section, denoted of the following:
"Warning: A correct indication on the fuel sight gages in the wing ribs is only possible when the aircraft is leveled.
Warning: There is a tendency to fly the CTLS-LSA with a small sideslip angle. Flight performance is only marginally affected but it can lead to the tanks emptying at different rates. In this case, it is recommended to raise the wing with the fuller tank in a gentle temporarily slip. This can be achieved with the help of the rudder trim, if installed. The aircraft should be returned to level flight after a few minutes and the fuel indication checked. The amount in the tanks should now be more even.
Warning: The tanks in the CTLS have return flow flapper valves on the fuel tank anti-sloshing rib (refer to Chapter 7 Systems Description). They prevent fuel from quickly flowing into the outer tank area during side slipping where it could not be fed into the engine. The return flow valve reduces but does not completely prevent return flow. An exact indication of fuel quantity is thus only possible at the wing root when, after a sideslip, the aircraft has returned to normal flight attitude (and the amount of fuel inside and outside the anti-sloshing rib has evened out)."
The CTSW flight manual did not contain similar verbiage, and neither the CTLS or CTSW manuals, nor any airplane placards or Flight Design USA safety directives made any recommendation regarding flight with one fuel tank empty.
ASTM Standards
The CTSW airplane was designed to comply with the ASTM Consensus Standards, F2245, Revision 4 (Design and Performance of a Light Sport Airplane). The standards make only one reference with regards to unusable fuel:
"7.3.1. The unusable fuel quantity for each tank must be
established by tests and shall not be less than the quantity at which the first evidence of engine fuel starvation occurs under each intended flight operation and maneuver."
By comparison, aircraft certified under 14 CFR Part 23 (Airworthiness Standards: Normal, Utility, Acrobatic, and Commuter Category Airplanes) must meet the following standards:
"23.959 (a) Unusable fuel supply. The unusable fuel supply for each tank must be established as not less than that quantity at which the first evidence of malfunctioning occurs under the most adverse fuel feed condition occurring under each intended operation and flight maneuver involving that tank."
CTSW Accident in the United Kingdom
The United Kingdom Department for Transport Air Accidents Investigation Branch (AAIB) investigated an accident on August 12, 2009, involving a similarly equipped CTSW airplane. The airplane experienced a fuel starvation event during the landing approach. It was subsequently determined that at that time, the right tank was empty, and the left tank contained about 1.32 gallons of fuel.
Testing performed during that accident investigation established that with 1.32 gallons of fluid in the right tank, and the wing set to an angle of 8 degrees, the sight gauge indicated that the tank was almost half full. Subsequent tests revealed that with the tank level, it continued to issue fluid at its outlet until only 0.132 gallons remained.
The investigation identified flight planning as a contributory factor and the AAIB issued a recommendation that, "Flight Design GmbH, together with P&M Aviation (the CTSW type certificate holder in the UK), revise their assessment of the unusable fuel in the CTSW aircraft."
P&M Aviation subsequently issued Service Bulletin SB 131. The service bulletin did not make any revisions to the unusable fuel quantity as recommended by the AAIB, but instead recommended a detailed series of actions with regard to monitoring fuel quantities, including the recommendation that both sight gauges must show fuel in flight, and that a landing should be performed if any gauge reads empty. The service bulletin further stated, "if one tank should empty before the other, in level flight the remaining fuel can still be used up....However, if the aircraft is in turbulence and/or the airplane is flown with sideslip putting the outboard end of the feeding tank low, it is possible for the feed to be uncovered and air to be drawn into the system causing the engine to stop."
Fuel Requirements
Federal Aviation Regulation 14 CFR 91.151, under Visual Flight Rules (VFR), "Fuel requirements for flight in VFR conditions" states in part, that no person may begin a flight in an airplane under VFR conditions unless (considering wind and forecast weather conditions) there is enough fuel to fly to the first point of intended landing and, assuming normal cruising speed during the day, to fly after that for at least 30 minutes.
History of Flight
Enroute-cruise
Fuel exhaustion (Defining event)
Loss of engine power (total)
Landing
Off-field or emergency landing
Landing-flare/touchdown
Collision with terr/obj (non-CFIT)
Pilot Information
Certificate: Sport Pilot
Age: 63
Airplane Rating(s): Single-engine Land
Seat Occupied: Unknown
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Sport Pilot None
Last FAA Medical Exam:
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time: (Estimated) 300 hours (Total, all aircraft), 300 hours (Total, this make and model)
Aircraft and Owner/Operator Information
Aircraft Manufacturer: FLIGHT DESIGN GMBH
Registration: N102HA
Model/Series: CTSW
Aircraft Category: Airplane
Year of Manufacture:
Amateur Built: No
Airworthiness Certificate: Special Light-Sport
Serial Number: 07-06-21
Landing Gear Type: Tricycle
Seats: 2
Date/Type of Last Inspection: 11/10/2012, Condition
Certified Max Gross Wt.: 1320 lbs
Time Since Last Inspection: 34 Hours
Engines: 1 Reciprocating
Airframe Total Time: 382.9 Hours at time of accident
Engine Manufacturer: ROTAX
ELT: C91A installed, not activated
Engine Model/Series: 912ULS
Registered Owner: BERNATH NICOLE OI-EN WONG
Rated Power: 100 hp
Operator: On file
Operating Certificate(s) Held: None
Meteorological Information and Flight Plan
Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: RDM, 3080 ft msl
Observation Time: 0056 UTC
Distance from Accident Site: 17 Nautical Miles
Direction from Accident Site: 100°
Lowest Cloud Condition: Clear
Temperature/Dew Point: 33°C / 2°C
Lowest Ceiling: None
Visibility: 10 Miles
Wind Speed/Gusts, Direction: 6 knots, 330°
Visibility (RVR):
Altimeter Setting: 29.79 inches Hg
Visibility (RVV):
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Sisters, OR (OR34)
Type of Flight Plan Filed: None
Destination: Sisters, OR (6K5)
Type of Clearance: None
Departure Time: 1755 PDT
Type of Airspace:
Airport Information
Airport: SISTERS EAGLE AIR (6K5)
Runway Surface Type: N/A
Airport Elevation: 3168 ft
Runway Surface Condition: Dry
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: None
Wreckage and Impact Information
Crew Injuries: 1 None
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 None
Latitude, Longitude: 44.303056, -121.531944 (est)
Darwin, or should it be Karma, Award winner. Buh-byyyyyy.
ReplyDeleteOr should it be suicide.....
ReplyDeleteWe need investigative aviation journalists more than ever.
ReplyDeleteInvestigative aviation journalists that file a lot of Freedom of Information (FOIA) requests.
ReplyDeleteBernath didn't work alone with threats, harassing, vile nasty lies, FAKE lawsuits and using peoples screen names as defendants. Finally a Judge banned the POS from filing lawsuits without a attorney. His partners in crime are Joseph Cry er (fake Navy Seal who claims he was recruited from a video arcade and Dallas WITTGENFELD aka the Purpleheart Parachutist a embellishing Assclown who threats to Cometh to rape and butcher women and children. Too bad the other to weren't passengers.
ReplyDeleteBTW..BERNATH was in the Virginia jail for 3+ months and released 1-19-2018 when he played guilty to violation of the restraining order.
ReplyDeleteDallas WITTGENFELD was released 12-24-17 from Maryland for the same thing.
68 YEAR OLD MAN JUST MAY HAVE HAD TIAS OR A BRAIN BLEED OR STROKE. CONFUSION WOULD BE NOTICEABLE. BUT SEEMS THE CONTROLLER DID NOT FORBID HIM TO TAKEOFF. BTW THAT "TRANSCRIPT" WAS HARD TO UNDERSTAND IN ITSELF.
ReplyDeleteMaybe ... But looks more like a lack of brains over a long period of time.
ReplyDeleteI wonder how many pilots have seen the claim that he was a Navy SEAL?
ReplyDeleteJustice served by an airplane. He got it.
ReplyDeleteDivine justice! This is an example of God taking care of business!
ReplyDelete