Wednesday, May 2, 2018

Van's RV-12, N276VA, registered to Yoxford Air LLC and operated by Chesapeake Sport Pilot: Fatal accident occurred April 19, 2016 near Bay Bridge Airport (W29), Stevensville, Queen Anne's County, Maryland

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

Analysis 

The airline transport pilot of the light sport airplane was approaching the airport for landing in gusty front quartering crosswind conditions. Witnesses observed the airplane on final approach between 50 and 75 ft above ground level. The airplane's nose pitched up, followed by a roll to the right. The airplane then entered a nose-down attitude and descended to ground contact, impacting level terrain about 750 ft from the runway and slightly left of the extended runway centerline. Examination of the wreckage did not reveal any preimpact mechanical malfunctions that would have precluded normal operation.

Before the accident flight, the pilot had about 2.4 hours of experience in the accident airplane make and model but had been signed off to fly the airplane by an instructor. Witness observations of the final moments of flight are consistent with an aerodynamic stall. It is likely that the pilot failed to compensate for the gusty crosswind and turbulent conditions during the approach for landing, which resulted in an exceedance of the airplane's critical angle of attack, aerodynamic stall, and subsequent loss of control. 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be: 

The pilot's failure to maintain airplane control during approach for landing in gusting crosswind conditions, which resulted in an exceedance of the airplane's critical angle of attack and a subsequent aerodynamic stall. 

Findings

Aircraft
Angle of attack - Not attained/maintained (Cause)
Airspeed - Not attained/maintained (Cause)

Personnel issues
Aircraft control - Pilot (Cause)

Environmental issues
Gusts - Effect on operation (Cause)
Gusts - Awareness of condition

Factual Information

History of Flight

Approach-VFR pattern final
Loss of control in flight (Defining event)

Uncontrolled descent
Collision with terr/obj (non-CFIT)

Richard W. Hess

After graduating in 1975 from the Naval Academy, Richard Hess was commissioned an officer and entered the naval flight program at Pensacola, Fla. Graduating at the top of his class and earning his wings in 1977.  Mr. Hess was assigned to Naval Air Station Whidbey Island, Wash., where he flew Grumman A-6 attack planes. Career assignments included tours in squadrons VA-128 Intruders, VA-95 Green Lizards and Va-165 Boomers, and command tours as executive officer and commanding officer of VA-52 Knightriders.

Bob Knowles, who was Mr. Hess' commanding officer at Whidbey Island in the late 1970s and early 1980s with VA-165, was also his navigator and bombardier. "Rick followed the rules, was very steady and never did anything stupid with the airplane, and he had some of the toughest flying in the squadron," said Mr. Knowles of Albuquerque, who retired in 1993 from the Navy with the rank of captain.  "The A-6 is built for the bombardier and not the pilot," said Mr. Knowles. "I wanted to fly with him, and that's why I chose him — and I could have chosen anyone. We were given really tough challenges, and we were able to pull them off. "He was a hell of a pilot, and if he was still alive, I'd still want to fly with him," he said. 

In 1986, Mr. Hess began a tour of duty at the Pentagon, where he was an aide to Secretary of the Navy John Lehman, and subsequently secretaries James H. Webb and William L. Ball.  Mr. Hess later flew in combat in Somalia and Iraq and was serving aboard the aircraft carrier USS Enterprise at the time of his retirement in 1996.

Janet Metz, 56, of Ellicott City, Maryland.
  Janet loved the zest and passion of taking on new challenges.


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

Additional Participating Entities: 

Federal Aviation Administration / Flight Standards District Office; Baltimore, Maryland 
Vans Aircraft; California, Maryland

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

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


http://registry.faa.gov/N276VA 


Lawrence A. McCarter, Investigator In Charge (IIC), National Transportation Safety Board.


Aviation Accident Factual Report - National Transportation Safety Board 


Location: Stevensville, MD
Accident Number: ERA16FA165
Date & Time: 04/19/2016, 1244 EDT
Registration: N276VA
Aircraft: VANS RV12
Aircraft Damage: Substantial
Defining Event: Loss of control in flight
Injuries: 2 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

On April 19, 2016, about 1244 eastern daylight time, a Vans RV-12, N276VA, was substantially damaged when it impacted terrain during final approach for landing at Bay Bridge Airport (W29), Stevensville, Maryland. The airline transport pilot and passenger were fatally injured. The airplane was registered to Yoxford Air, LLC, and operated by Chesapeake Sport Pilot under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the personal flight, which originated from Easton/Newnam Field Airport (ESN), Easton, Maryland.

The flight departed W29 about 1210 and proceeded to ESN, about 16 nautical miles southeast, where the pilot performed a full-stop landing and subsequent takeoff. The flight then departed the ESN traffic pattern and returned to W29 at an altitude about 1,500 ft.

Witnesses at W29 reported that they heard no transmissions from the pilot to the airport's common traffic advisory frequency (CTAF) as the airplane approached the airport. Flight track data showed the airplane enter the traffic pattern on a left downwind leg for runway 29 and remain at an altitude about 1,000 ft mean sea level then initiate a left descending turn to the base leg.

Multiple witnesses located near the airport observed the airplane on final approach and reported that it seemed unusually low about 50 to 75 ft. Several witnesses described the right wing drop before the airplane pitched nose-down and descended to the ground. Another witness reported that the airplane's flight path "seemed normal," then "suddenly, its nose pitched up briefly" followed by a bank to the right, then a nose-dive into the ground."

The airplane impacted terrain and cartwheeled about 75 ft before coming to rest upright about 750 ft short of runway 29 and slightly left of the extended runway centerline. A postimpact fire consumed the fuselage before it was extinguished by emergency responders about 10 minutes after the accident. 

Pilot Information

Certificate: Airline Transport; Flight Instructor
Age: 63, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): Airplane Single-engine
Toxicology Performed: Yes
Medical Certification: None None
Last FAA Medical Exam: 04/24/2008
Occupational Pilot: No
Last Flight Review or Equivalent: 
Flight Time: (Estimated) 5136 hours (Total, all aircraft), 2.8 hours (Total, this make and model) 

According to Federal Aviation Administration (FAA) records, the pilot, age 63, held an airline transport pilot certificate with ratings for airplane single- and multi-engine land. He also held a flight instructor certificate for airplane single engine. The pilot was issued an FAA first-class medical certificate in April 2008, which expired for all classes in April 2010. At the time of the accident, he did not possess an FAA medical certificate, nor was he required to for the accident flight in the light sport airplane. On the application for his last medical certificate, the pilot reported 5,136 total hours of flight experience. According to a review of the flight school's electronic records and correspondence with the owner of the school, the pilot completed two flights with a flight instructor in March and April 2016, totaling 2.4 hours of flight instruction and 3 hours of ground instruction. The pilot received an instructor signoff to fly the accident airplane on April 7, 2016. No pilot logbooks or additional flight records were recovered.

The flight instructor who provided the instruction and the signoff stated that the pilot had called several weeks earlier to receive a checkout in the RV-12 and stated that he did not have any experience in light sport aircraft. During the instruction flights, they performed various maneuvers, including steep turns, stalls, normal and soft field takeoffs, landings, and go-arounds. He stated that the pilot seemed "very comfortable" with the airplane and flew very well.



Aircraft and Owner/Operator Information

Aircraft Manufacturer: VANS
Registration: N276VA
Model/Series: RV12
Aircraft Category: Airplane
Year of Manufacture: 2015
Amateur Built: No
Airworthiness Certificate: Special Light-Sport
Serial Number: 12056
Landing Gear Type: Tricycle
Seats: 2
Date/Type of Last Inspection: 03/16/2016, 100 Hour
Certified Max Gross Wt.: 1320 lbs
Time Since Last Inspection:
Engines:  1 Reciprocating
Airframe Total Time: 314.8 Hours as of last inspection
Engine Manufacturer: Rotax
ELT: C126 installed, not activated
Engine Model/Series: 912
Registered Owner: Yoxford Air LLC
Rated Power: 100 hp
Operator: Yoxford Air LLC
Operating Certificate(s) Held: None
Operator Does Business As: Chesapeake Sport Pilot
Operator Designator Code: 

According to FAA records and the airframe manufacturer, the two-seat, low-wing, fixed landing gear airplane was manufactured by Van's Aircraft, Inc., and received its special airworthiness certificate for light sport on June 23, 2015. The airplane's most recent 100-hour inspection was completed on March 16, 2016. At the time of the inspection, the airplane had accrued 298.6 total hours of operation. The airplane was equipped with a Rotax 912-ULS-2 engine. The pilot's operating handbook stated that stall speed with the flaps extended at maximum gross weight was 41 knots; with the flaps retracted, the stall speed was 45 knots. The maximum direct crosswind was 11 knots.

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: ESN, 75 ft msl
Observation Time: 1645 UTC
Distance from Accident Site: 16 Nautical Miles
Direction from Accident Site: 130°
Lowest Cloud Condition: Scattered / 25000 ft agl
Temperature/Dew Point: 26°C / 6°C
Lowest Ceiling:
Visibility:  10 Miles
Wind Speed/Gusts, Direction: 10 knots/ 16 knots, 320°
Visibility (RVR):
Altimeter Setting: 30.02 inches Hg
Visibility (RVV):
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: EASTON, MD (ESN)
Type of Flight Plan Filed: None
Destination: Stevensville, MD (W29)
Type of Clearance: None
Departure Time: 1225 EDT
Type of Airspace: Class G

At 1248, the weather recorded at W29 included 10 miles visibility, temperature 26°C, dew point 6°C, and altimeter 29.99 inches of mercury (inHg).

At 1245, the reported weather at ESN included wind from 320° at 10 knots gusting to 16 knots, 10 miles visibility, scattered clouds at 25,000 ft, temperature 26°C, dew point 6°C, and an altimeter setting of 30.02 inHg.

The closest upper air sounding site was from Aberdeen Proving Grounds (APG), Maryland, located about 32 miles north-northeast of the accident site on the western shore of the Chesapeake Bay. The 0800 sounding indicated a morning surface-based inversion to about 800 ft. Winds were from the northwest at 10 knots and increasing in speed to over 20 knots immediately above the inversion. The strong shear resulted in a potential low-level wind shear conditions and turbulence. 

Airport Information

Airport: BAY BRIDGE (W29)
Runway Surface Type: Asphalt
Airport Elevation: 14 ft
Runway Surface Condition: Dry
Runway Used: 29
IFR Approach: None
Runway Length/Width: 2713 ft / 60 ft
VFR Approach/Landing: Traffic Pattern

W29 was a nontower-controlled airport. The field elevation was 15 feet msl and the airport was equipped with one asphalt runway. Runway 11/29 was 2,713 ft long by 60 ft wide and had nonprecision markings. Runway 29 was equipped with a 2-light precision approach path indicator (PAPI) with a 3.00° glidepath. The airport property was on the eastern shore of the Chesapeake Bay. 

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries: 1 Fatal
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Fatal
Latitude, Longitude: 38.975000, -76.322222 

The center fuselage and wings remained intact but were significantly damaged during the accident sequence. The wing spar remained attached to both wings and carried through the fuselage. Both wings remained attached to the U-channel with the spar pins locked in place. Fire consumed the center section of the airplane, where the 20-gallon fuel tank was located just aft of the cockpit seats, and also consumed the aft fuselage and empennage.

The left wing remained attached to the fuselage and carry-through wing spar. The outboard 90 inches remained intact to the wing root, where it was consumed by fire. The wing displayed very little compression and minor buckling on the forward outboard portion. The trailing edge displayed fire damage propagating outboard from the fuselage. The left flaperon remained attached and operated normally.

The right wingtip was deformed from the impact and the wing exhibited numerous compression bends along the entire span. It also exhibited fire damage at the root. The fire propagated outward from the midpoint of the wing aft and outboard of the trailing edge about 50% of its span. The right flaperon was ripped from its mounts and separated from the airplane during the accident sequence; it was found about 30 ft east of the main wreckage.

The aft root portions of the wings were destroyed by the fire. The flaperon handle was secured in the retracted position and the left flaperon displayed a neutral position. The right flaperon separated from the wing during the accident sequence and was found about 20 ft left of and behind the main wreckage. The push-pull tubes from the mixing box aft were broken and severed. The mixing box was not retrievable due to thermal damage.

The rudder was mostly destroyed by fire, but the lower attach point was functional and remained connected to the frame. Both rudder control cables remained attached. The stabilator remained intact and attached to the aft bulkhead. The counterweight and rod remained attached to the stabilator. The vertical stabilizer fractured just above the rear fuselage attach point. The forward attach point and lower and top ribs were consumed in the fire. The fiberglass tip was burned down to flexible cloth and the tail cone was consumed by fire.

Flight control continuity was established from the rudder and stabilator through the fuselage to the left and right tubular guides. Continuity to the rudder pedals could not be established due to impact and fire damage. All the cables were continuous and displayed minimal fire damage.

The engine, along with the mount and firewall, separated from the airframe and came to rest about 18 inches behind the cockpit. It was inverted and thermally damaged.

The crankshaft was turned via the aft accessory section of the engine and compression and suction were observed on all 4 cylinders. The spark plugs were examined; when compared to a Champion Spark Plug "Check-A-Plug" chart, the spark plugs appeared to be "normal" with light coloration signatures. Visual inspection of the valves and inside the cylinders at the exhaust pipes showed that they were clean, lubricated, and exhibited normal combustion signatures with no visible scoring or grooves.

There were two propeller witness marks in the ground leading up to the main wreckage, with one highly distinct gash 20 inches long and 8 inches deep in the ground. One blade separated at the hub. The other blade remained connected to the hub and was damaged by fire. 

Medical And Pathological Information

The Office of the Chief Medical Examiner, State of Maryland, Baltimore, Maryland, performed an autopsy of the pilot; the cause of death was multiple injuries. In addition, evidence of a scar from a previous stroke was identified, as well as significant heart disease. The pilot had an intact artificial aortic heart valve, severe coronary artery disease with 75% stenosis of the left anterior descending artery and 30% in the right coronary artery. No gross evidence of scarring from a previous heart attack was described. The medical examiner's toxicology testing identified amlodipine in the pilot's urine but not in blood.

The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicology testing and identified losartan, rosuvastatin, carvedilol, and salicylate in urine, amlodipine in liver and cavity blood, and rosuvastatin in blood. Losartan, carvedilol, and amlodipine are prescription blood pressure medications. Salicylate is a metabolite of aspirin; rosuvastatin is a prescription cholesterol lowering agent. None of these medications are generally considered impairing.

Records from the pilot's primary care doctor between April 2013 and April 2016 indicated that the pilot had undergone an aortic valve and aortic root replacement in 2012, and that he had longstanding hypertension and high cholesterol. He had also been diagnosed with a transient ischemic attack sometime before 2013. A list of regular medications was not included in the records after 2014.

Additional Information

According to the VANs RV-12 Pilot Operating Handbook. "During gusty wind conditions, fly the landing approach at approximately 5 knots above normal and touch down with the nose slightly lower than for a normal landing. Crosswind approaches can best be accomplished by using the wing down top rudder method touching first on the down wing side main wheel, followed by the other main wheel, and finally lowering the nose wheel all the while keeping the stick into the wind."

The Airplane Flying Handbook (FAA-H-8083-3B), Chapter 8, " Crosswind Approach and Landing," stated in part: The wing-low (sideslip) method compensates for a crosswind from any angle, but more important, it keeps the airplane's ground track and longitudinal axis aligned with the runway centerline throughout the final approach.

For landing in turbulent conditions, use a power-on approach at an airspeed slightly above the normal approach speed. This provides for more positive control of the airplane when strong horizontal wind gusts, or up and down drafts, are experienced. Like other power-on approaches, a coordinated combination of both pitch and power adjustments is usually required.
















NTSB Identification: ERA16FA165
14 CFR Part 91: General Aviation
Accident occurred Tuesday, April 19, 2016 in Stevensville, MD
Aircraft: VANS RV12, registration: N276VA
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 April 19, 2016 about 1244 eastern daylight time, a Vans RV-12, N276VA, registered to Yoxford Air, LLC. operated by a private individual, was substantially damaged when it impacted terrain during final approach at Bay Bridge Airport (W29), Stevensville, MD. The Airline Transport pilot and his passenger were fatally injured. Visual meteorological conditions prevailed, and no flight plan was filed for the local personal flight conducted under the provisions of Title14 Code of Federal Regulations Part 91.

At approximately 1210, the pilot and his passenger departed runway 29 at W29 and flew southeast for approximately 25 miles before returning to the airport 30 minutes later. Initial radar data indicated they approached the airport traffic pattern from the south at 1,000 feet and entered the traffic pattern on the left downwind leg for runway 29. After turning from base to final, several witnesses reported that the airplane looked unusually low on final approach. The nose pitched up briefly but the airplane did not did not appear to gain any altitude. The left wing appeared to rise, followed by a sharp turn to the right and steep nose down attitude before disappearing behind trees.

The airplane impacted the ground and cartwheeled for approximately 150 feet before coming to rest upright, approximately 750 feet short of runway 29 and slightly left of the extended runway centerline. A post-accident fire consumed the fuselage before it was extinguished by fire rescue personnel about 10 minutes after the accident.

According to Federal Aviation Administration (FAA) and pilot records, the pilot held a Airline Transport Pilot Certificate with ratings for Airplane Multiengine Land, Airplane Single Engine Land, and Flight Instructor for Airplane Single Engine Land. His most recent application for a FAA first-class medical certificate was dated April 24, 2008. As of his last known medical exam, the pilot reported that he had accrued approximately 5,136 total hours of flight experience. The pilot was issued a First Class Medical Certificate which expired for all classes on April 30, 2010.

According to FAA and maintenance records, the airplane was manufactured by Van's Aircraft, Inc. in 2015. The airplane's most recent 100 hour inspection was completed on March 16, 2016. At the time of the inspection, the airplane had accrued 298.6 total hours of operation. The airplane was equipped with a Rotax 912-ULS-2 engine.

The wreckage was retained by the NTSB for further examination.

1 comment:

Anonymous said...

The first time I looked at a completed RV-12, I noticed the fuel tank located behind the seats inside of the cockpit area. I thought to myself why did they not use wing tanks like the other RVs? I remember an article I read on how Wing tanks saved many lives vs. the cowl tanks on older biplanes and cubs, luscombs, etc. They also mention the a Model A Ford cowl tank hazard. Anyway, I feel bad for what happened. Maybe wing tanks would have helped.