Aerodynamic Stall/Spin: Piper PA-28-235 Cherokee 235, N8983W; fatal accident occurred September 20, 2016 at Lee's Summit Municipal Airport (KLXT), Missouri

Aviation Accident Final Report - National Transportation Safety Board

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

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Kansas City, Missouri
Piper Aircraft Company; Vero Beach, Florida 
Lycoming Aircraft Engines; Williamsport, Pennsylvania 

Investigation Docket - National Transportation Safety Board:

https://data.ntsb.gov/Docket

TEKO Air LLC

https://registry.faa.gov/N8983W

Location: Lee's Summit, MO
Accident Number: CEN16FA378
Date & Time: 09/20/2016, 1820 CDT
Registration: N8983W
Aircraft: PIPER PA 28-235
Aircraft Damage: Substantial
Defining Event: Aerodynamic stall/spin
Injuries: 2 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

The pilot and one passenger were on a cross-country flight in a single-engine airplane. Review of the airplane's radar flight track revealed that it was on a southerly heading to the destination airport and made a straight-in approach to runway 18. As the airplane neared the airport, a passenger filmed the approach section of the flight using her phone. A review of the footage showed that the approach appeared normal; however, during the landing flare, the airplane drifted slightly right. The camera then recorded the sound of the engine power increasing, followed immediately by the airplane touching down right of the runway centerline. The engine power then increases (likely either for a touch-and-go or for a go-around) and the airplane begins to climb in a right bank. The camera also captured images of the control yoke, which showed the pilot manipulating it aft and turning it left.

Several witnesses also reported seeing segments of the accident flight, and several of the airport's security cameras captured portions of the flight. A review of the videos and witness statements confirmed that the airplane touched down on the runway and then lifted off in a nose-high, right-wing-low attitude. The airplane then entered a steep right climbing turn; one witness reported that the airplane reached about 200 to 300 ft above ground level. The airplane then completed a 180° turn with about a 90° bank angle; entered a rapid descent; impacted terrain in a right-wing-down, nose-low attitude; slid along the ramp; and came to rest on its right side.

An examination of the engine and airframe did not reveal any preimpact abnormalities. Based on the available information, the pilot overcontrolled the airplane during takeoff, which resulted in it exceeding its critical angle of attack that led to an aerodynamic stall and loss of airplane control. 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's improper control inputs during takeoff, which resulted in the exceedance of the airplane's critical angle of attack and subsequent departure stall, and loss of airplane control.

Findings

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

Personnel issues
Incorrect action selection - Pilot (Cause)
Aircraft control - Pilot (Cause)
Total experience in position - Pilot

Factual Information

History of Flight

Takeoff
Aerodynamic stall/spin (Defining event)
Loss of control in flight

On September 20, 2016, about 1820 central daylight time, a Piper PA-28-235 airplane, N8983W, impacted terrain near Lee's Summit, Missouri. The pilot and passenger were fatally injured, and the airplane was substantially damaged. The airplane was registered to and operated by TEKO Air, LLC, Des Moines, Iowa, as a 14 Code of Federal Regulations Part 91 personal fight. Visual meteorological conditions existed near the accident site about the time of the accident, and no flight plan had been filed. The cross-country flight originated from Ankeny Regional Airport, Des Moines, Iowa, and was en route to Lee's Summit Municipal Airport (KLXT), Lee's Summit, Missouri.

A review of the airplane's radar flight track revealed that the airplane was on a southernly heading to KLXT and then made a straight-in approach to runway 18. As the airplane neared KLXT, a passenger filmed the approach section of the flight using her phone, which was found on scene. The camera captured portions of the approach to the runway. The approach appeared normal; however, during the landing flare, the airplane drifted slightly right. The camera then recorded the sound of the engine power increasing, followed immediately by the airplane touching down right of the runway centerline. The camera captured images of the control yoke, which showed the pilot manipulating it aft and turning it left. The sound was consistent with the engine at high power until the end of the recording. The National Transportation Safety Board's (NTSB) Personal Electronic Device Specialist's Factual Report is located in the docket for this accident.

Several witnesses reported seeing segments of the accident flight. Additionally, several of the airport's security cameras captured portions of the flight. A review of the security camera videos and witness statements revealed that the airplane touched down on runway 18 and then lifted off in a nose-high, right-wing-low attitude. The airplane then made a steep, right climbing turn; one witness reported that the airplane reached about 200 to 300 ft above ground level. The airplane completed a 180° turn with about a 90° bank angle and then entered a rapid descent, impacted terrain in a right-wing-down, nose-low attitude, slid along the ramp, and came to rest on its right side.

Pilot Information

Certificate: Private
Age: 53
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: Lap Only
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 09/28/2015
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time:  92.3 hours (Total, all aircraft), 64.1 hours (Total, this make and model) 

The pilot held a private pilot certificate, which was issued on June 9, 2016, with an airplane single-engine land rating. Additionally, he held a control tower operator certificate. The pilot was issued a third-class medical certificate on Sept 29, 2015. A review of the pilot's logbook revealed that he had 92.3 total flight hours, 18.2 hours of which were accrued since the pilot certificate was issued, with the last entry dated September 14, 2016. 

Aircraft and Owner/Operator Information

Aircraft Manufacturer: PIPER
Registration: N8983W
Model/Series: PA 28-235 235
Aircraft Category: Airplane
Year of Manufacture: 1964
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 28-10562
Landing Gear Type: Tricycle
Seats:
Date/Type of Last Inspection:  12/31/2015, Annual
Certified Max Gross Wt.:
Time Since Last Inspection:
Engines:  1 Reciprocating
Airframe Total Time: 2883.6 Hours at time of accident
Engine Manufacturer: LYCOMING
ELT: C91  installed, not activated
Engine Model/Series: 0-540 SERIES
Registered Owner: TEKO Air LLC
Rated Power: 250 hp
Operator: TEKO Air LLC
Operating Certificate(s) Held: None 

The accident airplane was a Piper PA-28-235, which is a low-wing, single-engine airplane with fixed landing gear. It was powered by a reciprocating 235-horsepower Lycoming, six-cylinder engine that drove a fixed-pitch propeller. A review of the airplane's maintenance records revealed that the last annual inspection was conducted on December 31, 2015, at a total time of 2,780.32 hours. A review of the engine maintenance records revealed that the engine was removed, overhauled, and reinstalled on August 22, 2016, at an airframe tachometer time of 2,822.2 hours. The tachometer read 2,883.6 hours at the accident site. 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KLXT
Observation Time: 1753 CDT
Distance from Accident Site:
Direction from Accident Site:
Lowest Cloud Condition: Clear
Temperature/Dew Point: 32°C / 23°C
Lowest Ceiling: None
Visibility: 10 Miles
Wind Speed/Gusts, Direction: 10 knots, 190°
Visibility (RVR):
Altimeter Setting:  30.04 inches Hg
Visibility (RVV):
Precipitation and Obscuration: No Precipitation
Departure Point: Ankeny, IA (KIKV)
Type of Flight Plan Filed: None
Destination: Lee's Summit, MO (KLXT)
Type of Clearance: VFR Flight Following
Departure Time:
Type of Airspace: 

At 1853, the weather observation facility at KLXT recorded wind from 190° at 10 knots, 10 miles visibility, clear sky, temperature 90°F, dew point 73°F, and an altimeter setting of 30.04 inches of mercury. 

Airport Information

Airport: Lee's Summit (KLXT)
Runway Surface Type: Asphalt
Airport Elevation: 1004 ft
Runway Surface Condition: Dry
Runway Used: 18
IFR Approach: None
Runway Length/Width: 4016 ft / 75 ft
VFR Approach/Landing:  Straight-in 

KLXT is a publicly owned, nontowered airport located 3 miles north of Lee's Summit, Missouri. Pilots are to use the common traffic advisory frequency for communications. KLXT has two concrete runways 18/36, which is 4,016 ft by 75 ft, and 11/29, which is 3,800 ft by 75 ft. The airport is at an elevation of 1,004 ft mean sea level. 

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries: 1 Fatal
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Fatal
Latitude, Longitude:  38.960556, -94.375556 

The on-site examination of the wreckage revealed that the airplane impacted terrain and an asphalt ramp just behind a building west of runway 18. Propeller cuts in the asphalt and ground scars were consistent with a right-wing-down, nose-low impact. The right wing had separated from the fuselage and was located about 92 ft from, and west of, the initial impact point. The wreckage path was 305 ft long and proceeded from the initial impact point on a heading of about 340° to the main wreckage, which consisted of the fuselage, left wing, empennage, and engine compartment. The two-bladed propeller had separated from the engine's crankshaft flange and was located about 20 ft beyond the main wreckage. About 8 inches of one propeller blade was torn off, whereas the other blade was severely distorted. There was no postcrash fire.

The airplane's left wing remained with the fuselage but was only partially attached. An undetermined amount of fuel remained in the left- and right-wing fuel tanks. An area near the right wing showed evidence of a fuel spill.

The main cabin floor and engine firewall were pushed back into the cabin area, and the front, right side of the fuselage had also sustained extensive damage. The top engine cowling was impact separated and was located along the wreckage path. The empennage sustained major damage to the right side of the stabilator.

Left aileron continuity was established from the control surface to the bellcrank; the aileron control and balance cable were attached to the left bellcrank, aileron control wheel chain, and right bellcrank. The right aileron remained attached; however, the control rod was broken, and the bellcrank had separated, pulled through wing ribs, and was found with the fuselage. Rudder control continuity was established to the cockpit rudder pedals. The flap handle was in the retracted position; however, due to damage to the flap controls, the actual position of the flaps during landing could not be determined.

The engine sustained impact damage and was examined on-site by the NTSB and a technical representative from the engine manufacturer. The engine was cut from the airframe and hung by a forklift to aid examination. The bottom set of spark plugs were removed and exhibited light-colored combustion deposits, and the electrodes exhibited normal wear signatures. The engine was rotated by hand; a thumb suction compression test was conducted, and continuity through the engine valve train and accessory section was confirmed. The left and right magnetos were removed from the engine and tested by hand; spark was observed on each terminal. The fuel pump and carburetor were examined, and no abnormalities were noted.

No preimpact abnormalities were noted during the airframe or engine examinations. 

Medical And Pathological Information

The Office of the Jackson County Medical Examiner, Kansas City, Missouri, conducted an autopsy on the pilot. The cause of death was determined to be "multiple blunt force injuries."

The Federal Aviation Administration's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, conducted toxicological testing on specimens from the pilot. The tests were negative for ethanol and tested drugs.

NTSB Identification: CEN16FA378
14 CFR Part 91: General Aviation
Accident occurred Tuesday, September 20, 2016 in Lee's Summit, MO
Aircraft: PIPER PA 28-235, registration: N8983W
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 September 20, 2016, about 1820 central daylight time, a Piper PA-28-235 airplane, N8983W, impacted terrain near Lee's Summit, Missouri. The private rated pilot and passenger were fatally injured, and the airplane was substantially damaged. The airplane was registered to and operated by TEKO Air LLC, Des Moines, Iowa, under the provisions of 14 Code of Federal Regulations Part 91 as a personal fight. Visual meteorological conditions prevailed and no flight plan had been filed. The cross country flight originated from the Ankeny Regional Airport (KIKV), Des Moines, Iowa, and was en route to the Lee's Summit Municipal airport, (KLXT), Lee's Summit, Missouri.

Several witnesses reported seeing segments of the airplane's accident flight. Additionally, several of the airport's security cameras captured a portion of the flight. A review of the security camera video's and witness statements, revealed the airplane touched down on KLXT's runway 18, the airplane then continued on the runway for a little way, before departing. The airplane was then seen with nose high, left wing low attitude. The airplane continued and entered into a right steep turn; one witness reported that the airplane was high as 200 to 300 ft above ground level. The airplane continued to make a 180-degree turn, with a wing bank angle of about 90 degrees. The airplane made a rapid decent, impacting terrain in a right wing, nose low attitude. The airplane then slid along the ramp for about 250 ft, coming to rest on its right side. 

After the initial on-site documentation of the wreckage, the airplane was recovered for further examination.

Kelli Brooke Basile 

Vincent Louis Basile II

Cessna 120, N1915N, registered to Aeronca Champ Club Inc and operated by a private individual: Accident occurred March 19, 2017 at Sackman Field Airport (H49), Columbia, Illinois

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

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; St. Ann, Missouri

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

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

Aeronca Champ Club Inc: http://registry.faa.gov/N1915N

Location: Columbia, IL
Accident Number: CEN17LA145
Date & Time: 03/19/2017, 0955 CDT
Registration: N1915N
Aircraft: CESSNA 120
Aircraft Damage: Substantial
Defining Event: Runway excursion
Injuries: 2 None
Flight Conducted Under: Part 91: General Aviation - Instructional 

Analysis 

The flight instructor reported that the purpose of the flight was to complete a tail-wheel endorsement for the pilot. After about 1 hour of total flight time, while attempting to take off for the fourth full-length runway departure, the flight instructor realized that the engine was not producing enough power for a successful takeoff, so he took control of the airplane and began applying maximum braking; however, the airplane departed the runway end, collided with a ditch, and then nosed over.

During postaccident examination of the airplane, no anomalies were found that would have precluded normal operation. Atmospheric conditions in the area were conducive to the formation of serious icing at cruise power. The flight instructor reported that he believed that carburetor icing led to the loss of engine power. He added that carburetor heat was applied before each landing but that it was turned off when they taxied for departure. Therefore, it is likely that carburetor ice accumulated during the taxi and that the carburetor heat was not on long enough to melt the ice before takeoff, which resulted in the partial loss of engine power. 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The partial loss of engine power due to carburetor icing.

Findings

Personnel issues
Identification/recognition - Instructor/check pilot (Cause)

Environmental issues
Conducive to carburetor icing - Effect on equipment (Cause)
Object/animal/substance - Contributed to outcome

Factual Information 

On March 19, 2017, at 0955 central daylight time, a Cessna 120 airplane, N1915N, was substantially damaged during a runway excursion at Sackman Field Airport (H49), Columbia, Illinois. The pilot receiving instruction and the flight instructor were not injured. The airplane was registered to Aeronca Champ Club LLC and operated by a private individual under the provisions of 14 Code of Federal Regulations Part 91 as an instructional flight. Visual meteorological conditions prevailed for the flight that operated without a flight plan. The local flight was originating at the time of the accident.

According to information provided by the flight instructor, the purpose of the flight was to complete a tail-wheel endorsement for the pilot. The accident occurred on the fourth full-length runway departure, after about one hour of total flight time. While taking off from runway 21, the airplane was 2/3 down the length of the runway when the flight instructor assessed that the engine was not developing enough power for a successful takeoff, so he took control of the airplane and began braking. With full brake application and about 700 ft remaining, the airplane slowed down but not enough to remain on the runway. The airplane exited the end of the runway and collided with a drainage ditch, entered a cultivated field and nosed over.

Inspectors from the Federal Aviation Administration responded to the accident site and visually examined the airplane. No anomalies were detected.

On the NTSB Form 6120, the flight instructor suspected carburetor icing as the reason of the loss of engine power. The flight instructor reported that carburetor heat was applied on each landing and after each landing, the carburetor heat was turned off as they taxied for departure.

A review of the Carburetor Icing Probability Chart located in the FAA's Special Airworthiness Information Bulletin CE-09-35, Carburetor Icing Prevention found that the airplane was operating in an area conducive to the formation of serious icing at cruise power. 

History of Flight

Takeoff
Fuel related
Loss of engine power (partial)

Takeoff-rejected takeoff
Runway excursion (Defining event)

Collision with terr/obj (non-CFIT)

On March 19, 2017, at 0955 central daylight time, a Cessna 120 airplane, N1915N, was substantially damaged during a runway excursion at Sackman Field Airport (H49), Columbia, Illinois. The pilot receiving instruction and the flight instructor were not injured. The airplane was registered to Aeronca Champ Club LLC and operated by a private individual under the provisions of 14 Code of Federal Regulations Part 91 as an instructional flight. Visual meteorological conditions prevailed for the flight that operated without a flight plan. The local flight was originating at the time of the accident.

According to information provided by the flight instructor, the purpose of the flight was to complete a tail-wheel endorsement for the pilot. The accident occurred on the fourth full-length runway departure, after about one hour of total flight time. While taking off from runway 21, the airplane was 2/3 down the length of the runway when the flight instructor assessed that the engine was not developing enough power for a successful takeoff, so he took control of the airplane and began braking. With full brake application and about 700 ft remaining, the airplane slowed down but not enough to remain on the runway. The airplane exited the end of the runway and collided with a drainage ditch, entered a cultivated field and nosed over.

Inspectors from the Federal Aviation Administration responded to the accident site and visually examined the airplane. No anomalies were detected.

On the NTSB Form 6120, the flight instructor suspected carburetor icing as the reason of the loss of engine power. The flight instructor reported that carburetor heat was applied on each landing and after each landing, the carburetor heat was turned off as they taxied for departure.

A review of the Carburetor Icing Probability Chart located in the FAA's Special Airworthiness Information Bulletin CE-09-35, Carburetor Icing Prevention found that the airplane was operating in an area conducive to the formation of serious icing at cruise power. 

Flight Instructor Information

Certificate: Flight Instructor; Commercial
Age: 59, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s): None
Restraint Used: 4-point
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): Airplane Multi-engine; Airplane Single-engine; Instrument Airplane
Toxicology Performed: No
Medical Certification: Class 2 Without Waivers/Limitations
Last FAA Medical Exam: 01/30/2017
Occupational Pilot: No
Last Flight Review or Equivalent: 05/23/2016
Flight Time: 1415 hours (Total, all aircraft), 17 hours (Total, this make and model), 1340 hours (Pilot In Command, all aircraft), 25 hours (Last 90 days, all aircraft), 9 hours (Last 30 days, all aircraft)

Pilot Information

Certificate: Private
Age: 40, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 4-point
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 3 Without Waivers/Limitations
Last FAA Medical Exam: 06/11/2013
Occupational Pilot: No
Last Flight Review or Equivalent: 02/06/2016
Flight Time: 690 hours (Total, all aircraft), 3 hours (Total, this make and model), 587 hours (Pilot In Command, all aircraft), 4 hours (Last 90 days, all aircraft), 3 hours (Last 30 days, all aircraft) 

Aircraft and Owner/Operator Information

Aircraft Manufacturer: CESSNA
Registration: N1915N
Model/Series: 120 NO SERIES
Aircraft Category: Airplane
Year of Manufacture: 1947
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 12159
Landing Gear Type: Tailwheel
Seats:
Date/Type of Last Inspection: 03/27/2016, Annual
Certified Max Gross Wt.: 1450 lbs
Time Since Last Inspection: 81 Hours
Engines: 1 Reciprocating
Airframe Total Time: 4656 Hours at time of accident
Engine Manufacturer: CONT MOTOR
ELT: C91  installed, not activated
Engine Model/Series: C85 SERIES
Registered Owner: AERONCA CHAMP CLUB INC
Rated Power: 85 hp
Operator: AERONCA CHAMP CLUB INC
Operating Certificate(s) Held: None 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KCPS, 413 ft msl
Observation Time: 0953 CST
Distance from Accident Site: 8 Nautical Miles
Direction from Accident Site: 28°
Lowest Cloud Condition: Thin Overcast / 8000 ft agl
Temperature/Dew Point: 7°C / 0°C
Lowest Ceiling: Overcast / 8000 ft agl
Visibility: 10 Miles
Wind Speed/Gusts, Direction: 10 knots, 140°
Visibility (RVR):
Altimeter Setting: 30.37 inches Hg
Visibility (RVV):
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Columbia, IL (H49)
Type of Flight Plan Filed: None
Destination: Columbia, IL (H49)
Type of Clearance: None
Departure Time: 0955 CDT
Type of Airspace: Airport Information
Airport: SACKMAN FIELD (H49)
Runway Surface Type: Grass/turf
Airport Elevation: 420 ft
Runway Surface Condition: Vegetation
Runway Used: 21
IFR Approach: None
Runway Length/Width: 2450 ft / 150 ft
VFR Approach/Landing:  None 

Wreckage and Impact Information

Crew Injuries: 2 None
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 None
Latitude, Longitude:  38.452222, -90.236111

NTSB Identification: CEN17LA145 
14 CFR Part 91: General Aviation
Accident occurred Sunday, March 19, 2017 in Columbia, IL
Aircraft: CESSNA 120, registration: N1915N
Injuries: 2 Uninjured.

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 March 19, 2017, at 0955 central daylight time, a Cessna 120 airplane, N1915N, was substantially damaged during a runway excursion at Sackman Field Airport (H49), Columbia, Illinois. The pilot receiving instruction and the flight instructor were not injured. The airplane was registered to Aeronca Champ Club LLC and operated by a private individual under the provisions of 14 Code of Federal Regulations Part 91 as an instructional flight. Visual meteorological conditions prevailed for the flight that operated without a flight plan. The local flight was originating at the time of the accident.

According to information obtained by the Federal Aviation Administration, while taking off from runway 21, the pilots reported that the engine was not producing sufficient power. The pilot attempted to abort of takeoff, but insufficient runway remained for the airplane to stop on the turf strip. The airplane overran the strip, collided with a ditch, and nosed over in a field.

The airplane was retained for further examination.

Robinson R44 Raven II, N728CB, operated by Chesapeake Bay Helicopters: Accident occurred April 27, 2017 in Newton, Catawba County, North Carolina

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

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Charlotte, North Carolina
Lycoming Engines; Williamsport, Pennsylvania 
Robinson Helicopter Company; Torrance, California 

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

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

  

Bulanov Galis LLC: http://registry.faa.gov/N728CB

Analysis 

The commercial helicopter pilot and a crewmember were conducting a pipeline patrol when they noticed a right-of-way infraction (construction work) that they wanted to photograph. The pilot then entered a left circuit at 500 ft above ground level. The pilot reported that he subsequently felt a shudder in the controls and that the helicopter began to yaw right and spin. Although the pilot reported that he maintained an airspeed of 70 knots while maneuvering, GPS data revealed that the loss of yaw control occurred at the completion of the first left circuit and the beginning of the second left circuit as the helicopter slowed to a groundspeed of about 1 mph. Weather data indicated that, at this point, the helicopter was experiencing an 8-knot tailwind. The pilot lowered the helicopter's nose but was unable to correct the spin. He entered an autorotation and maneuvered to avoid residences and utility poles, and the helicopter then impacted the ground.

Examination of the helicopter did not reveal any evidence of preimpact mechanical malfunctions that would have precluded normal operation. It is likely that the low-airspeed condition combined with a tailwind during out-of-ground-effect maneuvering resulted in a loss of helicopter control due to a loss of tail rotor effectiveness. 

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 an adequate airspeed during out-of-ground-effect maneuvering at a low airspeed with a tailwind, which resulted in a loss of helicopter control due to a loss of tail rotor effectiveness.

Findings

Aircraft
Airspeed - Not attained/maintained (Cause)

Personnel issues
Aircraft control - Pilot (Cause)

Environmental issues
Tailwind - Effect on operation (Cause)

Location: Newton, NC
Accident Number: ERA17LA168
Date & Time: 04/27/2017, 1330 EDT
Registration: N728CB
Aircraft: ROBINSON R44
Aircraft Damage: Substantial
Defining Event: Loss of tail rotor effectiveness
Injuries: 2 Minor
Flight Conducted Under: Part 91: General Aviation - Aerial Observation 

On April 27, 2017, about 1330 eastern daylight time, a Robinson R44 II, N728CB, operated by Chesapeake Bay Helicopters, was substantially damaged during a collision with terrain while maneuvering near Newton, North Carolina. The commercial pilot and crewmember sustained minor injuries. The local aerial observation flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and a company flight plan was filed for the flight that originated from Concord Regional Airport (JQF), Concord, North Carolina, about 1225.

The pilot reported that he was performing a pipeline patrol at 500 ft above ground level and an airspeed of 70 knots. During the patrol, the crew observed a right-of-way infraction and circled the location at the same airspeed and altitude. While extending the circling pattern, the pilot felt a shudder in the controls while at the same time, the nose of the helicopter yawed right and the helicopter began to spin. He immediately lowered the nose in an attempt to increase forward motion, but the rate of spin increased. He then attempted to set up for an autorotation and avoid residences and utility wires. The helicopter subsequently impacted the ground and the pilot was able to shut down the engine and exit the helicopter.

The crewmember reported that while on pipeline patrol, they circled to photograph construction work. While circling, the helicopter lost control and spun two or three times before impacting the ground.

Examination of the wreckage revealed substantial damage to the helicopter. Tail rotor driveshaft continuity was confirmed from the tail rotor blades to the main rotor. Continuity was also confirmed from the left anti-torque pedal to the tail rotor. A section of right anti-torque pedal control tube was found bent and separated. The separated section of control tube was retained for metallurgical examination, which revealed that the separation was consistent with overstress due to impact forces. No preimpact mechanical malfunctions were identified.

The helicopter's most recent 100-hour inspection was completed on March 10, 2017. At that time, the airframe and engine had accumulated 1,873.6 total hours of operation. The helicopter had flown an additional 43.6 hours from the time of the inspection, until the accident flight.

The recorded wind at an airport located about 10 miles northwest of the accident site, at 1253, was from 190° at 8 knots.

Review of GPS data provided by the operator revealed that after completion of the first left circuit and the beginning of the second left circuit, the helicopter's ground speed slowed to about 1 mph at a GPS altitude of 1,223 ft (about 500 ft above ground level). At that time, the GPS track was indicating a northerly course, with an approximate 8-knot tailwind. The track subsequently indicated transition from a left circuit to a right turn.

The Federal Aviation Administration issued advisory circular (AC)-90-95, Unanticipated Right Yaw in Helicopters during February 1995. The AC stated that the loss of tail rotor effectiveness (LTE) was a critical, low-speed aerodynamic flight characteristic which could result in an uncommanded right yaw rate that did not subside of its own accord and, if not corrected, could result in the loss of aircraft control. It also stated, "LTE is not related to a maintenance malfunction and may occur in varying degrees in all single main rotor helicopters at airspeeds less than 30 knots."

Paragraph 9 of the AC covered reducing the onset of LTE. It stated:

"In order to reduce the onset of LTE, the pilot should: ... c. When maneuvering between hover and 30 knots: (1) Avoid tailwinds. If loss of translational lift occurs, it will result in an increased high power demand and an additional anti-torque requirement. (2) Avoid out of ground effect (OGE) hover and high power demand situations, such as low speed downwind turns. (3) Be especially aware of wind direction and velocity when hovering in winds of about 8 - 12 knots (especially OGE). There are no strong indicators to the pilot of a reduction of translation lift... (6) Stay vigilant to power and wind conditions."

Paragraph 10 of the AC addressed recovery techniques. It stated:

"a. If a sudden unanticipated right yaw occurs, the pilot should perform the following:
(1) Apply full left pedal. Simultaneously, move cyclic forward to increase speed. If altitude permits, reduce power. (2) As recovery is effected, adjust controls for normal forward flight. b. Collective pitch reduction will aid in arresting the yaw rate but may cause an increase in the rate of descent. Any large, rapid increase in collective to prevent ground or obstacle contact may further increase the yaw rate and decrease rotor rpm. c. The amount of collective reduction should be based on the height above obstructions or surface, gross weight of the aircraft, and the existing atmospheric conditions. d. If the rotation cannot be stopped and ground contact is imminent, an autorotation may be the best course of action. The pilot should maintain full left pedal until rotation stops, then adjust to maintain heading."

Additionally, Robinson Safety Notice SN-34 addressed aerial survey and photography flights, and provided cautions about such flights below 30 knots airspeed. 

Pilot Information

Certificate: Commercial
Age: 34, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s): Helicopter
Restraint Used: 3-point
Instrument Rating(s): Airplane; Helicopter
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 2 Without Waivers/Limitations
Last FAA Medical Exam: 08/29/2016
Occupational Pilot: Yes
Last Flight Review or Equivalent: 11/22/2016
Flight Time:  1529 hours (Total, all aircraft), 207 hours (Total, this make and model), 111 hours (Last 90 days, all aircraft), 14 hours (Last 30 days, all aircraft), 9 hours (Last 24 hours, all aircraft) 

Aircraft and Owner/Operator Information

Aircraft Manufacturer: ROBINSON
Registration: N728CB
Model/Series: R44 II
Aircraft Category: Helicopter
Year of Manufacture: 2010
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 12899
Landing Gear Type: Skid;
Seats: 4
Date/Type of Last Inspection: 03/10/2017, 100 Hour
Certified Max Gross Wt.: 2500 lbs
Time Since Last Inspection: 43 Hours
Engines: 1 Reciprocating
Airframe Total Time: 1917 Hours at time of accident
Engine Manufacturer: LYCOMING
ELT: Not installed
Engine Model/Series: IO-540-AE1A5
Registered Owner: BULANOV GALIS LLC
Rated Power: 245 hp
Operator: Chesapeake Bay Helicopters
Operating Certificate(s) Held: Rotorcraft External Load (133)

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: HKY, 1186 ft msl
Observation Time: 1253 EDT
Distance from Accident Site: 10 Nautical Miles
Direction from Accident Site: 310°
Lowest Cloud Condition:
Temperature/Dew Point: 21°C / 13°C
Lowest Ceiling: Overcast / 4600 ft agl
Visibility:  8 Miles
Wind Speed/Gusts, Direction: 8 knots, 190°
Visibility (RVR):
Altimeter Setting: 29.88 inches Hg
Visibility (RVV):
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Concord, NC (JQF)
Type of Flight Plan Filed: Company VFR
Destination: Concord, NC (JQF)
Type of Clearance: None
Departure Time:  1225 EDT
Type of Airspace:

Wreckage and Impact Information

Crew Injuries: 2 Minor
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Minor
Latitude, Longitude:  35.633333, -81.243889


NTSB Identification: ERA17LA168
14 CFR Part 91: General Aviation
Accident occurred Thursday, April 27, 2017 in Newton, NC
Aircraft: ROBINSON HELICOPTER COMPANY R44 II, registration: N728CB
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 April 27, 2017, about 1330 eastern daylight time, a Robinson R44 II, N728CB, operated by Chesapeake Bay Helicopters, was substantially damaged during a collision with terrain while maneuvering near Newton, North Carolina. The commercial pilot and crewmember incurred minor injuries. The local aerial observation flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and a company flight plan was filed for the flight that originated from Concord Regional Airport (JQF), Concord, North Carolina, about 1225.

The pilot reported that he was performing a pipeline patrol at 500 feet above ground level and an airspeed of 70 knots. During the patrol, the crew observed a right-of-way infraction and circled the location at the same airspeed and altitude. While extending the circling pattern, the pilot felt a shudder in the controls while at the same time, the nose of the helicopter yawed right and the helicopter began to spin. He immediately lowered the nose in an attempt to increase forward motion, but the rate of spin increased. He then attempted to set up for an autorotation and avoid residences and utility wires. The helicopter subsequently impacted the ground and the pilot was able to shut down the engine and exit the helicopter.

The observer reported that while on pipeline patrol, they circled to photograph construction work. While circling, the helicopter lost control and spun two or three times before impacting the ground.

Examination of the wreckage revealed substantial damage to the helicopter. Tailrotor driveshaft continuity was confirmed from the tailrotor blades to the main rotor. Continuity was also confirmed from the left anti-torque pedal to the tailrotor. A section of right anti-torque pedal control tube was found bent and separated. The separated section of control tube was retained for metallurgical examination.

The helicopter's most recent 100-hour inspection was completed on March 10, 2017. At that time, the airframe and engine had accumulated 1,873.6 total hours of operation. The helicopter had flown and additional 43.6 hours from the time of the inspection, until the accident flight.

The recorded wind at an airport located about 10 miles northwest of the accident site, at 1253, was from 190° at 8 knots.

Piper PA-23-250 Aztec E, N21WW, operated by Air America Inc: Fatal accident occurred June 03, 2017 in San Juan, Puerto Rico

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

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; San Juan, Puerto Rico
Lycoming Engines; Williamsport, Pennsylvania
Piper Aircraft; Vero Beach, Florida
Hartzell Propeller; Piqua, Ohio

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

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

Air America Inc: http://registry.faa.gov/N21WW

Location: San Juan, PR
Accident Number: ERA17FA195
Date & Time: 06/03/2017, 1417 AST
Registration: N21WW
Aircraft: PIPER PA23
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight
Injuries: 1 Fatal, 2 Serious, 1 Minor
Flight Conducted Under: Part 135: Air Taxi & Commuter - Non-scheduled 

Analysis 

The commercial pilot was conducting an on-demand air taxi flight with three passengers on board the multiengine airplane. The majority of the pilot's multiengine experience was in a larger airplane with more powerful engines. He had about 20 hours of experience in the accident airplane make and model and had completed training in it about 9 days before the accident. The pilot stated that, after receiving clearance for takeoff from air traffic control, he performed the takeoff roll and rotated the airplane at 85 knots. The airplane climbed to about 100 ft above ground level (agl), but then did not continue to climb or accelerate. The airplane then yawed left, and the left engine rpm needle indicated less than the right engine rpm, but it remained in the green arc. Subsequently, the pilot turned the airplane left with the yaw to return to the airport, but the airplane was unable to maintain altitude and subsequently impacted water. The pilot further stated that, other than the rpm difference, there were no other preimpact mechanical malfunctions with the airplane.

The front seat passenger reported that he was not a pilot but that he was familiar with airplanes. He stated that the airplane initially gained some altitude, but that it then yawed left. He then noticed that the pilot did not correct the yaw and let the airplane turn perpendicular to the wind, at which point he mentally questioned the pilot's competency and felt compelled to take the controls, but he did not touch anything. The airplane lost altitude and then flew under a tree line while remaining in a left banking turn. The pilot then moved the yoke abruptly right, and the airplane collided with the water. The front seat passenger added that the sound of the engines did not change during the flight and that he noted no smoke or fuel odor.

Airport surveillance video confirmed that the airplane climbed to about 100 to 150 ft agl, which is out of ground effect, as it passed over the departure end of the runway. The airplane remained in a nose-up attitude as it then began to descend and, begin a shallow left turn; it then impacted the water.

Examination of the airplane did not reveal any preimpact mechanical malfunctions that would have precluded normal operation, and the airplane was about 350 lbs below its maximum gross weight. Additionally, the airplane was equipped with constant-speed propellers, and a loss of left engine power would have been noticeable on the manifold pressure gauge and not the rpm gauge.

The airplane's airspeed indicator revealed that mph were depicted by the larger numbers on the outer ring and that knots were depicted by the smaller numbers on the inner ring. Given the airspeed indicator's configuration, it is likely that the pilot rotated and then attempted to climb the airplane at 85 mph and not 85 knots, but either airspeed was significantly less than airplane's best rate-of-climb speed of 120 mph (102 knots). It is likely that the airplane climbed at the lower airspeed until out of ground effect, but then could not maintain a climb and began to descend back into ground effect. Further, the airplane was not equipped with counter-rotating engines to offset the left yaw at slower airspeeds, and the airplane began to yaw to the left. Rather than lower the nose, correct for the yaw, and continue straight into a 15-knot headwind to increase airspeed, the pilot allowed the airplane to continue to yaw left and exceeded the airplane's critical angle of attack, which resulted in an aerodynamic stall and subsequent descent into water.

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 adequate airspeed, properly correct for left yaw, and his exceedance of the airplane's critical angle of attack during initial climb, which resulted in an aerodynamic stall and subsequent uncontrolled descent into water. 

Findings

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

Personnel issues
Aircraft control - Pilot (Cause)

Factual Information

History of Flight

Initial climb
Loss of engine power (total)
Loss of control in flight (Defining event)

Uncontrolled descent

Collision with terr/obj (non-CFIT)

On June 3, 2017, about 1417 Atlantic standard time, a Piper PA-23-250, N21WW, impacted water and a reef shortly after takeoff from Luis Munoz Marin International Airport (TJSJ), San Juan, Puerto Rico. The commercial pilot sustained minor injuries, two passengers were seriously injured, and one passenger was fatally injured. The airplane was destroyed. The flight was being operated by Air America, Inc., as a Title 14 Code of Federal Regulations Part 135 on-demand air taxi flight. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed for the planned flight to Benjamin Rivera Noriega Airport (TJCP), Isla de Culebra, Puerto Rico.

According to air traffic control (ATC) information provided by the Federal Aviation Administration (FAA), the flight was cleared for an intersection takeoff on runway 8 from taxiway S5. Runway 8 was 10,400 ft long, and the intersection takeoff at S5 allowed about half of the runway length for takeoff. At 1414:09, the pilot contacted ATC and stated that he was ready for takeoff. The tower controller replied that there was about 30 seconds left of a wake turbulence delay due to an Embraer 190 that had departed about 2 minutes 30 seconds earlier. The pilot waived the delay, and the tower controller cleared the flight for takeoff at 1414:26. At 1416:33, the tower controller instructed the pilot to contact departure control; however, the pilot stated that he was "unable" and was returning to the airport. At 1416:46, the pilot stated, "we are trying hard we lost power on an engine we're trying to go back." The controller asked what engine, and the pilot replied, "we… [lost] an engine." No further communications were received from the pilot.

Review of radar data revealed that, at 1415:52, the airplane was near the departure end of the runway, indicating an altitude of 100 ft. The last radar target was recorded at 1416:16, about 1,000 ft beyond the departure end of the runway, indicating an altitude of 0 feet (about 100 ft agl). Review of airport surveillance video revealed that the airplane had lifted off the runway by about 1415:40 and had climbed to between about 100 and 150 ft agl, out of ground effect, as it passed over the departure end of the runway at 1416:01. The airplane remained in a nose-up attitude and began to descend; it then entered a shallow left turn at 1416:17. The airplane continued turning left at a low altitude to a position consistent with the left downwind leg of the airport traffic pattern and then disappeared from the camera's view at 1416:43. The airplane reappeared in the camera's view as it impacted water about .75 mile abeam the departure end of runway 8 at 1417:07.

According to the pilot's written statement and recorded interview, after he completed a preflight inspection, the passengers walked toward the airplane. The pilot then completed a final walkaround and visually checked the fuel in the fuel tanks. After the baggage was loaded and the passengers boarded the airplane, the pilot performed a safety/emergency briefing and started the engines. He received instructions from ATC to taxi to runway 8 via N taxiway and to hold short of the runway at S5. The pilot performed a run-up using the checklist, and everything was within acceptable parameters.

After receiving clearance for takeoff from ATC, the pilot performed a takeoff roll and rotated the airplane at 85 knots. About 100 ft agl, he retracted the landing gear and noted that the airplane did not seem to be climbing or accelerating beyond 85 to 90 knots. He verified that the magnetos and fuel pumps were on and that the throttle, mixture, and propeller levers were in the "full forward" position. He also noted that all the engine instruments were in the green arc normal operating range. The airplane then yawed left, and the pilot noticed that the left engine rpm was less than the right, but that it remained in the green arc. The pilot subsequently turned left with the yaw to return to the airport, but the airplane was unable to maintain altitude. He then attempted to avoid a populated beach and ditched in shallow water. The pilot did not remember how he exited the airplane, but recalled that his face burned when he swam to the water's surface because of a fire. He tried two more times to reach the water's surface far enough away from the fire. He then saw two of the three passengers and attempted to swim back for the third passenger, but was in shock and had ingested too much water. A person on a paddle board then pulled the pilot from the water.

During a postaccident interview with two FAA inspectors, the front seat passenger stated that he was not a pilot, but that he was familiar with airplanes because he was an aerospace engineer and had spent some time in a Boeing 757 simulator with a friend. He stated that the pilot did not provide a safety briefing and that, instead, he (the front seat passenger) instructed the other passengers (minors) to fasten their seatbelts, and he fastened his seatbelt. As the airplane approached the runway, the pilot secured the door and started the takeoff process without reading any checklist. The airplane initially gained some altitude, but it then yawed left. The front seat passenger then noticed that the pilot did not correct the yaw and let the airplane turn perpendicular to the wind, at which point, he mentally questioned the pilot's competency and felt compelled to take the controls, but he did not touch anything. The airplane lost altitude and flew under a tree line while remaining in a left banking turn. The pilot then moved the yoke abruptly right, and the airplane collided with the water.

The front seat passenger reported that the pilot egressed first, but he did not recall how because the door was on the passenger's side of the airplane. The front seat passenger then egressed, followed by one other passenger. The third passenger did not egress, and the front seat passenger tried to go back toward the airplane, but the fire was too intense, and he was badly burned. The front seat passenger added that the sound of the engines did not change during the flight and that he noted no smoke or fuel odor. 

 

Molly Catherine Wrede

Molly Wrede, 15, died June 3, 2017. A lithe athlete on the volleyball court and graceful dancer on stage, her infectious spirit was boundless. A smile always at the ready, her wry sense of humor could be counted on to lighten any mood

Pilot Information

Certificate: Commercial
Age: 22, 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 Multi-engine; Airplane Single-engine
Toxicology Performed: Yes
Medical Certification: Class 1 With Waivers/Limitations
Last FAA Medical Exam: 12/14/2016
Occupational Pilot: Yes
Last Flight Review or Equivalent:
Flight Time: 1200 hours (Total, all aircraft), 20 hours (Total, this make and model), 121 hours (Last 90 days, all aircraft), 49 hours (Last 30 days, all aircraft), 5 hours (Last 24 hours, all aircraft) 

The pilot held a commercial pilot certificate with ratings for airplane single-engine land, airplane multiengine land, and instrument airplane. He also held a flight instructor certificate with ratings for airplane single-engine and airplane multiengine. The pilot's most recent FAA first-class medical certificate was issued on December 14, 2016. The pilot reported a total flight experience of about 1,200 hours, about 200 hours of which were in multiengine airplanes and about 20 hours of which were in the accident airplane make and model.

Review of company records revealed that the pilot was hired in December 2016 and completed ground and flight training. At the time of his hire, he reported a total flight experience of 900 hours, 110 hours of which were in multiengine airplanes. From December 2016 through May 2017, the pilot flew about 220 hours in a Britten-Norman BN-2A-21 Islander, which could carry up to nine passengers and was equipped with two 300-horsepower Lycoming engines. The pilot completed training in the accident airplane make and model on May 25, 2017. He had accumulated about 20 hours in it during the 6 months before the accident. At the time of the accident, the last recorded entry in the pilot's logbook was dated February 28, 2017. At that time, the logbook indicated that the pilot had accumulated a total flight experience of about 933 hours, 234 hours of which were in multiengine airplanes.

Review of the pilot's FAA records revealed that he received a Notice of Disapproval of Application for a private pilot certificate on November 8, 2014. The pilot subsequently obtained his private pilot certificate on November 12, 2014. The pilot then obtained a multiengine rating during his first attempt on December 4, 2014. He received another Notice of Disapproval of Application for an instrument rating on January 30, 2015. The notice included comments that, upon reapplication, the pilot would be reexamined on preflight preparation and preflight procedures. He subsequently obtained an instrument rating on February 6, 2015. The pilot obtained a commercial pilot license (single-engine land) during his first attempt on March 18, 2015. He also obtained a commercial pilot certificate (multiengine land and instrument airplane) during his first attempt on April 11, 2015.

The pilot received another Notice of Disapproval of Application for a flight instructor certificate (multiengine rating) on June 16, 2015. The notice included comments that the pilot needed to review and understand the airplane's systems. The pilot subsequently obtained his flight instructor certificate with a multiengine rating on July 7, 2015. At that time, the pilot reported a total flight experience of 221 hours, 96.9 hours of which were in multiengine airplanes. The pilot received another Notice of Disapproval of Application for a flight instructor certificate (single-engine rating) on July 14, 2015. The notice included comments that the pilot needed more training teaching takeoffs and landings. The pilot subsequently obtained his flight instructor certificate with a single-engine rating on July 22, 2015. 

Aircraft and Owner/Operator Information

Aircraft Manufacturer: PIPER
Registration: N21WW
Model/Series: PA23 250
Aircraft Category: Airplane
Year of Manufacture:
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 27-7554066
Landing Gear Type: Retractable - Tricycle
Seats: 6
Date/Type of Last Inspection: 11/16/2016, Annual
Certified Max Gross Wt.: 5200 lbs
Time Since Last Inspection: 95 Hours
Engines: 2 Reciprocating
Airframe Total Time: 9182 Hours at time of accident
Engine Manufacturer: LYCOMING
ELT: C126 installed, activated, did not aid in locating accident
Engine Model/Series: IO-540-C4B5
Registered Owner: AIR AMERICA INC
Rated Power: 250 hp
Operator: AIR AMERICA INC
Operating Certificate(s) Held: Commuter Air Carrier (135) 

The six-seat, low-wing, tricycle-retractable-gear airplane was manufactured in 1975. It was powered by two Lycoming IO-540, 250-horsepower engines, each equipped with a Hartzell controllable pitch full-feathering propeller. According to maintenance records, the airplane's most recent annual inspection was completed on November 16, 2016. At that time, the airframe had accumulated 9,087.3 total hours of operation, and the engines had accumulated 695.3 hours since major overhaul. The airplane had flown about 95 hours from the time of that inspection until the accident.

Review of the airspeed indicator revealed that mph were depicted in the larger numbers on an outer ring and that knots were depicted in the smaller numbers on the inner ring. The airplane was not equipped with counter-rotating engines to offset yaw at slower airspeeds. 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: TJSJ, 9 ft msl
Observation Time: 1421 EDT
Distance from Accident Site: 1 Nautical Miles
Direction from Accident Site: 210°
Lowest Cloud Condition: Few / 2400 ft agl
Temperature/Dew Point: 31°C / 24°C
Lowest Ceiling: None
Visibility:  10 Miles
Wind Speed/Gusts, Direction: 17 knots, 70°
Visibility (RVR):
Altimeter Setting:
Visibility (RVV):
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: San Juan, PR (TJSJ)
Type of Flight Plan Filed: IFR
Destination: Isla de Culebra, PR (TJCP)
Type of Clearance: IFR
Departure Time: 1415 AST
Type of Airspace:

The recorded weather at TJSJ, at 1421, was wind from 070° at 17 knots; visibility 10 miles; few clouds at 2,400 ft, scattered clouds at 4,000 ft, and scattered clouds at 7,000 ft; temperature 31°C; dew point 24°C; and altimeter setting 29.98 inches of mercury. 

Airport Information

Airport: LUIS MUNOZ MARIN INTL (TJSJ)
Runway Surface Type: Asphalt
Airport Elevation: 9 ft
Runway Surface Condition: Dry
Runway Used: 08
IFR Approach: None
Runway Length/Width: 10400 ft / 200 ft
VFR Approach/Landing: Precautionary Landing 

Wreckage and Impact Information

Crew Injuries: 1 Minor
Aircraft Damage: Destroyed
Passenger Injuries: 1 Fatal, 2 Serious
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: On-Ground
Total Injuries: 1 Fatal, 2 Serious, 1 Minor
Latitude, Longitude: 18.460278, -65.972778 (est) 

Examination of the wreckage following recovery to a hangar revealed that both wings had separated during impact. The right wing exhibited leading edge impact damage and buckling at the outboard section. The right flap and right aileron had separated from the wing and were recovered. The right engine remained attached to the wing, and the right propeller remained attached to the engine. The two propeller blades appeared undamaged and were in the normal operating range and not in a feathered position. The valve covers, spark plugs, oil filter, and vacuum pump were removed from the right engine. The spark plug electrodes, vacuum pump vanes, and drive coupling were intact. When the propeller was rotated by hand, crankshaft, camshaft, and valve train continuity were confirmed to the rear accessory section, and thumb compression was attained on all cylinders. The fuel injector servo and magnetos were removed. The fuel injector servo screen was absent of debris. Fuel was recovered from the fuel line to the engine-driven pump, the engine-driven fuel pump, the fuel line to the fuel servo, and the fuel servo. The fuel odor was consistent with 100 low lead aviation gasoline. The left magneto did not produce spark when rotated by hand, consistent with saltwater immersion. The right magneto produced spark at five of the six leads. The right flow divider attachment bolts were found loose. Two of the flow divider lines had separated, consistent with impact, and one line was found loose, and its B-nut was removed by hand with two turns. The fuel injector nozzles were unobstructed.

The left wing exhibited leading edge impact damage and buckling at the outboard section. The left flap remained attached to the wing. The left aileron had separated and was recovered. The left engine remained attached to the wing, and the left propeller remained attached to the engine. One propeller blade appeared undamaged, and the other blade was bent aft, but both blades were in the normal operating range and not in a feathered position. The valve covers, spark plugs, oil filter, and vacuum pump were removed from the left engine. The spark plug electrodes, vacuum pump vanes, and drive coupling were intact. When the propeller was rotated by hand, crankshaft, camshaft, and valve train continuity were confirmed to the rear accessory section, and thumb compression was attained on all cylinders. The fuel injector servo and magnetos were removed. The fuel injector servo screen was absent of debris. Fuel was recovered from the fuel line to the engine driven fuel pump, the engine-driven fuel pump, the fuel line to the fuel servo, the fuel servo, and the flow divider. The fuel odor was consistent with 100 low lead aviation gasoline. The fuel inlet hose B-nut at the fuel servo was loose. The magnetos did not produce spark when rotated by hand, consistent with saltwater immersion. Five of the six fuel injector nozzles were unobstructed, and one nozzle was obstructed. The oil filter element and oil suction screen were absent of metallic contamination.

Examination of the cockpit revealed that the landing gear and flaps were in the "retracted" position. The seatbelts and shoulder harnesses remained intact. The master switch was in the "off" position, and the left and right fuel pumps were in the "on" position. The left magneto switches were in the "on" position, and the right magneto switches were in the "off" position. Underwater photographs provided by law enforcement revealed that the right throttle lever was forward, whereas the right mixture and propeller levers were midrange. The left throttle lever was midrange, whereas the left propeller and mixture levers were forward. However, the preimpact positions of the levers could not be verified because the wings had separated during impact. The left engine fuel selector was found positioned to the left inboard main fuel tank position, and the right engine fuel selector was found positioned to the right outboard main fuel tank position. The crossfeed switch was found midrange and fragmented. Measurement of the rudder trim jackscrew corresponded to a neutral rudder trim position. Measurement of the stabilator trim jackscrew corresponded to full nose-up stabilator trim position, but damage was present near the jackscrew, and its trim indicator cable had separated. Control continuity was confirmed from the rudder to the rudder pedals in the cockpit. Continuity was also confirmed from the stabilator to the cockpit area. Aileron continuity was confirmed from the respective aileron bellcranks, through the separated wing roots, to the cockpit area. 

Medical And Pathological Information

The FAA's Bioaeronautical Science Research Laboratory, Oklahoma City, Oklahoma, conducted toxicological testing on a serum sample from the pilot. The results were negative for alcohol.

Tests And Research

The lap belt that secured the deceased passenger was retained and forwarded to an National Transportation Safety Board Survival Factors Specialist for further examination. The examination did not reveal any preimpact mechanical malfunctions, and the insert tab released from the buckle when the latch was lifted about 90°. 

Additional Information

Fuel

The airplane was equipped with six fuel tanks. Each wing had a 36-gallon inboard fuel tank, a 36-gallon outboard fuel tank, and a 24-gallon auxiliary wingtip tank. The pilot reported that "all tanks" were full; however, the fueler stated that he always filled the four main fuel tanks, but not the auxiliary fuel tanks. The former director of operations of the operator stated that the auxiliary fuel tanks were usually left empty. The estimated fuel onboard at takeoff was 144 gallons in the four full main fuel tanks, or 864 lbs.

Weight and Balance

Review of the pilot's operating manual (POM) for the make and model airplane revealed that the airplane's maximum gross takeoff weight was 5,200 lbs. The pilot had calculated the airplane's weight for the accident takeoff as 4,335 lbs. A recalculation was completed after the accident based on the four main fuel tanks being full of fuel. The recalculation also included the weights of the front seat occupants (220 lbs and 190 lbs) and the middle seat occupants (115 lbs and 120 lbs). The recalculation also included 125 lbs of baggage, which was in the rear of the airplane. The recalculated weight and balance revealed that the accident takeoff weight was about 4,850 lbs, which was 350 lbs below the maximum takeoff weight. The center of gravity was near the forward limit.

Performance


Review of a takeoff performance chart from the POM revealed that, given the conditions that existed at the time of the accident, 88°F, at sea level, at a takeoff weight of 4,850 lbs, and with a 15-knot headwind, the airplane required about 1,250 ft to take off and climb over a 50-ft obstacle. However, the performance chart noted a liftoff speed of 80 mph (70 knots) and the speed at the obstacle at 97 mph (84 knots). Further, the POM stated that the best angle-of-climb speed was 107 mph (93 knots) and that the best rate-of-climb speed was 120 mph (102 knots). The airplane's single-engine rate-of-climb speed was 240 ft per minute, with a best single-engine rate-of-climb speed of 102 mph (89 knots).

NTSB Identification: ERA17FA195
Nonscheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Saturday, June 03, 2017 in San Juan, PR
Aircraft: PIPER PA23, registration: N21WW
Injuries: 1 Fatal, 2 Serious, 1 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 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 June 3, 2015, about 1418 Atlantic standard time, a Piper PA-23-250, N21WW, operated by Air America Inc., was destroyed during impact with water and a reef, and a subsequent postcrash fire, shortly after takeoff from Luis Munoz Marin International Airport (TJSJ), San Juan, Puerto Rico. The commercial pilot sustained minor injuries, two passengers were seriously injured, and one passenger was fatally injured. The on-demand air taxi flight was conducted under the provisions of 14 Code of Federal Regulations Part 135. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed for the planned flight to Benjamin Rivera Noriega Airport, (TJCP), Isla de Culebra, Puerto Rico.

According to preliminary information from the Federal Aviation Administration (FAA), the flight was cleared for an intersection takeoff on runway 8 from taxiway S5. Runway 8 was 10,400 feet long and the intersection takeoff at S5 allotted approximately half of the runway length. Shortly after takeoff, the pilot reported an engine failure and no further communications were received from the accident flight. The airplane subsequently turned left an impacted shallow water and a reef located about .75 mile abeam the departure end of runway 8.

According to the pilot's written statement, about 100 feet above ground level, he retracted the landing gear and noted that the airplane did not seem to be climbing or accelerating like normal. He verified that the magnetos and fuel pumps were on, and that the throttle, mixture, and propeller levers were in the full forward position. He also noted that all the engine instruments were in the green arc normal operating range. The airplane then yawed left and the pilot noticed that the left engine rpm was less than the right. The pilot subsequently turned left with the yaw to return to the airport, but was unable to maintain altitude. He also attempted to avoid a populated beach and ditched in shallow water.

Examination of the wreckage following recovery to a hangar revealed that both wings separated during impact. The right wing exhibited leading edge impact damage and buckling at the outboard section. The right flap and right aileron had separated from the wing and were also recovered. The right engine remained attached to the wing and the right propeller remained attached to the engine. The two propeller blades appeared undamaged and not in a feathered position. The valve covers, spark plugs, oil filter, and vacuum pump were removed from the right engine. The spark plug electrodes were intact and the vacuum pump vanes and drive coupling were also intact. When the propeller was rotated by hand, crankshaft, camshaft, and valve train continuity were confirmed to the rear accessory section and thumb compression was attained on all cylinders. The fuel injector servo and magnetos were also removed. The fuel injector servo screen was absent of debris. Fuel was recovered from the fuel line to engine driven pump, the engine driven fuel pump, the fuel line to the fuel servo, and in the fuel servo. The fuel was consistent in odor to 100 low lead aviation gasoline. The left magneto did not produce spark when rotated by hand, consistent with saltwater immersion. The right magneto produced spark at five of the six leads. The right flow divider attach bolts were found loose. Two of the flow divider lines had separated consistent with impact and one line was found loose and its B-nut was removed by hand with two turns. The fuel injector nozzles were unobstructed. The left engine oil filter element and left engine oil suction screen were absent of metallic contamination.

The left wing exhibited leading edge impact damage and buckling at the outboard section. The left flap remained attached to the wing. The left aileron had separated and was also recovered. The left engine remained attached to the wing and the left propeller remained attached to the engine. One propeller blade appeared undamaged and the other blade was bent aft, but both blades were not in a feather position. The valve covers, spark plugs, oil filter, and vacuum pump were removed from the left engine. The spark plug electrodes were intact and the vacuum pump vanes and drive coupling were also intact. When the propeller was rotated by hand, crankshaft, camshaft, and valve train continuity were confirmed to the rear accessory section and thumb compression was attained on all cylinders. The fuel injector servo and magnetos were also removed. The fuel injector servo screen was absent of debris. Fuel was recovered from the fuel line to the engine driven fuel pump, the engine driven fuel pump, the fuel line to the fuel servo, the fuel servo, and in the flow divider. The fuel was consistent in odor to 100 low lead aviation gasoline. The fuel inlet hose B-nut at the fuel servo was not tight. The magnetos did not produce spark when rotated by hand, consistent with saltwater immersion. Five of the six fuel nozzles were unobstructed and one was obstructed.

Review of the cockpit revealed that the landing gear and flaps were in the retracted position. The seatbelts and shoulder harnesses remained intact. The master switch was in the off position and the left and right fuel pumps were in the on position. The left magneto switches were in the on position and the right magneto switches were in the off position. Underwater photographs provided by law enforcement revealed that the right throttle lever was forward, while the right mixture and propeller levers were midrange. The left throttle lever was midrange while the left propeller and mixture levers were forward. However, the preimpact positions of the levers could not be verified as the wings separated during impact. The left engine fuel selector was found positioned to the left inboard main fuel tank position and the right engine fuel selector was found positioned to the right outboard main fuel tank. The crossfeed switch was found midrange and fragmented. Measurement of the rudder trim jackscrew corresponded to a neutral rudder trim position. Measurement of the stabilator trim jackscrew corresponded to full nose-up stabilator trim position, but damage was present near the jackscrew and its trim indicator cable had separated. Control continuity was confirmed from rudder to the rudder pedals in the cockpit. Continuity was also confirmed from the stabilator to the cockpit area. Aileron continuity was confirmed from the respective aileron bellcranks, through the separated wing roots, to the cockpit area.

The pilot held a commercial pilot certificate, with ratings for airplane single-engine land, airplane multiengine land, and instrument airplane. He also held a flight instructor certificate, with ratings for airplane single-engine and airplane multiengine. The pilot's most recent FAA first-class medical certificate was issued on December 14, 2016. The pilot reported a total flight experience of approximately 1,200 hours; of which about 200 hours were in multiengine airplanes and of those about 20 hours were in the accident airplane make and model.

The six-seat, low wing, tricycle retractable gear airplane was manufactured in 1975. It was powered by two Lycoming IO-540, 250-horsepower engines, each equipped with a Hartzell controllable pitch full-feathering propeller. According to maintenance records, the airplane's most recent annual inspection was completed on November 16, 2016. At that time, the airframe had accumulated 9,087.3 total hours of operation and the engines had accumulated 695.3 hours since major overhaul. The airplane had flown about 95 hours from the time of that inspection, until the accident.

The recorded weather at TJSJ, at 1421, was: wind from 070 degrees at 17 knots; visibility 10 miles; few clouds at 2,400 feet, scattered clouds at 4,000 feet, scattered clouds at 7,000 feet; temperature 31 degrees C; dew point 24 degrees C; altimeter 29.98 inches of mercury.