Saturday, December 15, 2018

Cessna 421B Golden Eagle, N421KL: Fatal accident occurred March 04, 2017 at Cherokee County Airport (KCNI), Ball Ground, Georgia

 Steven Silver

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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Atlanta, Georgia
Continental Motors; Mobile, Alabama
Textron Aviation; Wichita, Kansas

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


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





Location: Canton, GA
Accident Number: ERA17FA118
Date & Time: 03/04/2017, 0023 EST
Registration: N421KL
Aircraft: CESSNA 421
Aircraft Damage: Substantial
Defining Event: Loss of control in flight
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 



HISTORY OF FLIGHT

On March 4, 2017, about 0023 eastern standard time, a Cessna 421B, N421KL, was substantially damaged during an attempted go-around and subsequent collision with terrain at Cherokee County Airport (CNI), Canton, Georgia. The commercial pilot was fatally injured. The airplane was registered to and was being operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91. Night visual meteorological conditions prevailed, and no flight plan was filed for the personal cross-country flight. The flight originated about 1930 on March 3, 2017, from Richard Lloyd Jones Jr Airport (RVS), Tulsa, Oklahoma, and was destined for CNI.

According to personnel at an aviation brokerage company in Oklahoma, the pilot purchased the airplane on March 2, 2017. A flight instructor reported that he and the pilot flew the airplane on March 1, 2017, for 1.5 hours to go over the various systems of the Cessna 421B. On March 2, 2017, the flight instructor flew with the pilot again for 45 minutes conducting pattern work. The flight instructor said that the pilot told him that he had previously owned two Cessna 421Cs, was a little "rusty," and had not flown that type of airplane since 1984. The instructor reported that, overall, the pilot was knowledgeable of the operation of airplane. He also reported that the pilot departed with enough fuel for the cross-country flight. A review of the pilot's logbook revealed that the flight instructor signed off a flight review on March 3, 2017.

Radar and audio data obtained from the Federal Aviation Administration (FAA) revealed that the pilot was in contact with air traffic control and receiving visual flight rules (VFR) flight following services while inbound to CNI. The pilot cancelled flight following when he had the airport in sight. Radar data continued to show the airplane on approach to CNI until 2,500 ft when the airplane descended below radar coverage.

A review of airport video surveillance footage revealed that the runway lights were illuminated during the airplane's approach to runway 05. The airplane's landing lights became visible as the airplane neared the runway. On short final, the airplane pitched up and rolled to the right. The airplane then descended in a nose-down attitude into a ravine on the right side of the runway. The video footage stopped for a second, and then a fire was seen in the ravine.

Witnesses observed the airplane flying extremely low before noticing a "ball of fire" erupt near the airport.



PERSONNEL INFORMATION

The 69-year-old pilot held a commercial pilot certificate with ratings for airplane single-engine land and instrument airplane. On his most recent FAA second-class medical certificate application, dated April 13, 2016, he reported a total flight experience of 4,000 hours with no hours flown during the last 6 months. The medical certificate indicated a limitation for glasses for near vision. A review of the pilot's current logbook, which was labeled logbook No. 3, revealed a total of 11.9 hours of flight experience since January 16, 2017.

AIRCRAFT INFORMATION

The multi-engine airplane was manufactured in 1970, and it was powered by two Continental GTSIO-520-series engines driving Hartzell PHC-C3YD-2UF controllable-pitch propellers. The most recent annual inspection was completed on March 1, 2017, at a recording hour meter time of 2,048.4 hours. The right engine was a GTSIO-520-D21CH engine, serial number 219483-R; it had a total time of 2,048.4 hours and a time since overhaul of 38.2 hours at the last inspection. The left engine was a GTSIO-520-H engine, serial number 218284-R; it had a total time of 2,048.4 hours and a time since overhaul of 430.9 hours.



METEOROLOGICAL INFORMATION

At 0010, the recorded weather at CNI included calm wind, 10 miles visibility, and clear skies. The temperature was 5°C; the dew point was -15°C; and the altimeter setting was 30.54 inches of mercury.

WRECKAGE AND IMPACT INFORMATION

Examination of the accident site revealed that the airplane contacted a wire about 380 ft to the right of the runway and parallel the runway. The airplane came to rest in a retention pond about 420 ft on the right of the runway centerline and runway threshold. The nose of the airplane was crushed aft, and the wind screen on the left side was broken away from the fuselage. Examination of the cockpit revealed that the instrument panel was crushed toward the left side of the fuselage. The flap control was in the fully extended position. The left engine throttle control was full forward, and the right engine throttle control was at the halfway mark. The left mixture control was full rich, and the right mixture control was at the halfway mark. The left propeller control was at the halfway mark, and the right propeller control was full forward. The left fuel selector handle was in the left main tank position, and the right fuel selector handle was in the right main tank position. Examination of the flight controls revealed continuity from the cockpit to all the flight control surfaces.

The left wing from the engine nacelle outboard exhibited postimpact fire damage. Fire damage exposed the main fuel tank attachment and baffle, which were intact. The left engine nacelle also showed signs of fire damage. The wing flaps were observed in the extended position.

Examination of the right wing revealed that it remained intact with very little postimpact fire damage, which was confined to the area around the engine nacelle. Fuel was observed in the right main fuel tank, the right-wing auxiliary tank, and the right nacelle locker tank; about 25 gallons of fuel were drained from the tanks. The right main fuel tank exhibited striations and flattening to the upper surface of the tank, which were consistent with a contact with a wire. Leading edge damage to the right wing was observed, which was consistent with contact with a wire. A power wire was observed wrapped around the right main landing gear. The wing flaps were observed in the extended position. Examination of the empennage revealed that the vertical stabilizer, horizontal stabilizer, rudder, and elevators remained attached. Both horizontal stabilizers were buckled.

All three landing gear were broken away from the airplane at the struts. The landing gear trunnions were observed in the down positions. The landing gear handle in the cockpit was observed in the down position.

Examination of the left engine revealed that it remained partially attached to the airframe by two engine mounts, hoses, wires, and cables. The engine displayed impact damage as well as some thermal damage to the rear of the engine. The crankcase remained intact and displayed impact damage. All the cylinders remained attached to their cylinder bays and displayed varying amounts of impact damage. The internal portions of the cylinders were inspected using a lighted borescope. The piston faces, valve heads, and cylinder bores did not display any anomalies. The crankshaft was rotated, and all six cylinders had thumb compression and suction. The overhead components (valves, springs, and rocker arms) were examined and did not display any anomalies. The external components of the engine (fuel pump, throttle, metering unit, and both magnetos) remained attached and displayed thermal damage. The ignition harness remained attached to both magnetos and displayed impact damage to the No. 2 and the No. 6 bottom ignition leads. All the spark plugs remained secured in their cylinders. The spark plugs were removed, and it was noted that all the electrodes displayed normal operating signatures when compared to Champion Aviation Service Manual AV6-R. The magnetos were removed, and both magneto drive shafts were rotated using an electric drill. The spark plugs were installed onto the ignition harness, and it was noted that all the spark plugs sparked between the ground and center electrodes.

The left turbocharger remained attached to the airframe and displayed minor impact damage. The wastegate remained attached to its installation point and was undamaged. The compressor and the turbine were undamaged and did not display any anomalies. The exhaust system displayed impact damage, and no signs of exhaust leaks were noted.

Examination of the right engine revealed that it remained partially attached to the airframe and displayed impact and thermal damage. All six cylinders remained attached to their cylinder bays and displayed varying amounts of impact damage. The internal portions of the cylinders were inspected using a lighted borescope; the cylinder bores, piston faces, and valve heads displayed normal operating and combustion signatures. The crankshaft was rotated, and all six cylinders had good thumb compression and suction. The overhead components (valves, springs, and rocker arms) were examined and did not display any anomalies. The external components of the engine (fuel pump, throttle, metering unit, and both magnetos) remained attached and displayed impact and thermal damage. The ignition harness displayed impact damage signatures to the No. 6 bottom ignition lead, which was partially severed. The magnetos were removed, and both magneto drive shafts were rotated using an electric drill. The magnetos produced spark on all six posts individually. The spark plugs were removed and visually inspected. All the spark plugs displayed normal operating and wear signatures when compared to Champion Aviation Service Manual AV6-R. The spark plugs were installed onto the ignition harness, and it was noted that all the spark plugs sparked between the ground and center electrodes.

The right turbocharger remained attached to the airframe and displayed minor impact damage. The wastegate remained attached to its installation point and was undamaged. The compressor and the turbine were undamaged and did not display any anomalies. Rotation and continuity were established between the two sections of the turbine and compressor. There were no signs of induction leaks noted. The exhaust system displayed impact damage throughout the exhaust system. There were no signs of exhaust leaks noted.

An examination of the propellers revealed that the blades on both propellers exhibited chordwise/rotational scoring on the camber sides, leading edge gouging, bending aft, and twisting leading edge down. One blade on each propeller had a fractured tip. Two blades on each propeller had fractured pitch change knobs with damage indicating the blades were forcibly rotated towards low pitch. The preload plate impact marks on both propellers were similar, indicating operation at or near the low pitch stop angle. There were no discrepancies noted that would have prevented or degraded normal propeller operation before impact. All damage to the propellers was consistent with high impact forces.

A JPI FS-450 fuel monitoring device was recovered from the wreckage and sent to the NTSB Recorders Laboratory for data download. Upon arrival in the lab, an internal examination revealed thermal damage. The device was reassembled, and power was applied; however, the device would not power on, and no data was obtained from the device.



MEDICAL AND PATHOLOGICAL INFORMATION

The Division of Forensics Sciences, Georgia Bureau of Investigation, Decatur, Georgia, performed an autopsy on the pilot. The cause of death was noted as multiple blunt force trauma.

The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed forensic toxicology on specimens from the pilot. Atorvastatin was identified in liver and cavity blood. Clonazepam and its metabolite 7-aminoclonazepam, hydrocodone and its active metabolite dihydrocodeine, diphenhydramine, nortriptyline, and temazepam were identified in liver. In addition, 0.031 ug/ml of 7-aminoclonazepam, 0.016 ug/ml of hydrocodone, an unquantified amount of dihydrocodeine, 0.129 ug/ml of diphenhydramine, an unquantified amount of nortriptyline, and 0.068 ug/ml of temazepam were identified in cavity blood. The toxicology testing identified the pilot had evidence of having used 5 different impairing medications.

Clonazepam is a sedating benzodiazepine often called Klonopin that is used to treat panic disorder and certain kinds of epilepsy. It is available by prescription as a Schedule IV substance. It impairs cognitive and physical performance and carries this warning, "Since clonazepam produces central nervous system (CNS) depression, patients receiving this drug should be cautioned against engaging in hazardous occupations requiring mental alertness, such as operating machinery or driving a motor vehicle. They should also be warned about the concomitant use of alcohol or other CNS- depressant drugs during clonazepam therapy.
Hydrocodone is an opioid pain medication available by prescription as a Schedule II controlled substance. Commonly available in combination with acetaminophen (commonly called Tylenol), tablets may also carry names such as Norco, Lorcet, and Vicodin. Hydrocodone "exposes users to the risks of addiction, abuse, and misuse" and "profound sedation, respiratory depression, coma, and death may result from the concomitant use of hydrocodone … with benzodiazepines or other CNS depressants (e.g., non-benzodiazepine sedatives/hypnotics, anxiolytics, tranquilizers, muscle relaxants, general anesthetics, antipsychotics, other opioids, alcohol)." The range of blood levels where hydrocodone is considered to have psychoactive effects is between 0.01 and 0.05 ug/ml.

Diphenhydramine is a sedating antihistamine used to treat allergy symptoms and as a sleep aid. It is available over the counter under the names Benadryl and Unisom. Diphenhydramine carries the following warning: may impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery). Compared to other antihistamines, diphenhydramine causes marked sedation; it is also classed as a CNS depressant and this is the rationale for its use as a sleep aid. Altered mood and impaired cognitive and psychomotor performance may also be observed. In fact, in a driving simulator study, a single dose of diphenhydramine impaired driving ability more than a blood alcohol concentration of 0.100%. The therapeutic range of diphenhydramine is 0.0250 to 0.1120 ug/ml. Diphenhydramine is widely distributed throughout the body and brain after an oral dose. Typical blood levels within 2-3 hours after oral ingestion of 50-100 mg are about 0.100 ug/ml. However, diphenhydramine undergoes post mortem redistribution where after death, the drug can leech from storage sites back into blood. Central post mortem levels may be about two to three times her than peripheral levels.

Nortriptyline is a tricyclic antidepressant, often marketed with the name Pamelor. It carries this warning about performance: "may impair the mental and/or physical abilities required for the performance of hazardous tasks, such as operating machinery or driving a car."

Temazepam is a sedating benzodiazepine medication available by prescription as a Schedule IV controlled substance and often marketed with the name Restoril. It is indicated for the short-term treatment of insomnia (generally 7 to 10 days). It carries a black box warning (the strongest level) regarding prescribing in combination with opioids: "Concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death." In addition, there is this precaution, "If temazepam is to be combined with other drugs having known hypnotic properties or CNS-depressant effects, consideration should be given to potential additive effects." Finally, there are warnings about the potential for bizarre behaviors and "there have been reports of people getting out of bed after taking a sedative-hypnotic and driving their cars while not fully awake, often with no memory of the event. If a patient experiences such an episode, it should be reported to his or her doctor immediately, since "sleep-driving" can be dangerous. This behavior is more likely to occur when temazepam is taken with alcohol or other central nervous system depressants." The range of blood levels where temazepam is considered to have psychoactive effects is between 0.017 and 0.132 ug/ml. 



Pilot Information

Certificate: Commercial
Age: 69, Male
Airplane Rating(s): Multi-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: Lap Only
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 04/13/2016
Occupational Pilot: No
Last Flight Review or Equivalent: 03/03/2017
Flight Time:  (Estimated) 11.9 hours (Total, all aircraft), 11.9 hours (Total, this make and model)

Aircraft and Owner/Operator Information

Aircraft Make: CESSNA
Registration: N421KL
Model/Series: 421 B
Aircraft Category: Airplane
Year of Manufacture:
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 421B0015
Landing Gear Type: Retractable - Tricycle
Seats: 7
Date/Type of Last Inspection: 03/01/2017, Annual
Certified Max Gross Wt.: 7200 lbs
Time Since Last Inspection: 30 Hours
Engines: 2 Reciprocating
Airframe Total Time: 7522.4 Hours
Engine Manufacturer: CONT MOTOR
ELT: C126 installed, activated, did not aid in locating accident
Engine Model/Series: GTSIO-520-D21
Registered Owner: ROGERS MICHAEL W
Rated Power: 340 hp
Operator: On file
Operating Certificate(s) Held: None 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Night
Observation Facility, Elevation: CNI, 1219 ft msl
Distance from Accident Site: 0 Nautical Miles
Observation Time: 0510 UTC
Direction from Accident Site: 0°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: Calm /
Turbulence Type Forecast/Actual: /
Wind Direction:
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 30.54 inches Hg
Temperature/Dew Point: 3°C / -15°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Tulsa, OK (RVS)
Type of Flight Plan Filed: VFR
Destination: Canton, GA (CNI)
Type of Clearance: VFR
Departure Time: 2030 CST
Type of Airspace: Class D



Airport Information

Airport: Cherokee County Airport (CNI)
Runway Surface Type: Asphalt
Airport Elevation: 1219 ft
Runway Surface Condition: Dry
Runway Used: 05
IFR Approach: None
Runway Length/Width: 5001 ft / 75 ft
VFR Approach/Landing: Straight-in

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude:  34.546667, -84.800000

Midair Collision: Piper PA-28R-200 Arrow II, N4407T and Luscombe 8A, N2889K; fatal accident occurred December 31, 2016 near Aero Country Airport (T31), McKinney, Collin County, Texas

Greg and Tim Barber

Robert Navar


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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Dallas, Texas
Piper Aircraft Company; Vero Beach, Florida

N4407T Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf 


N4407T Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms 



N4407T Aviation Accident Data Summary - National Transportation Safety Board:  https://app.ntsb.gov/pdf

http://registry.faa.gov/N4407T





Location: McKinney, TX
Accident Number: CEN17FA063A
Date & Time: 12/31/2016, 1725 CST
Registration: N4407T
Aircraft: PIPER PA28R
Aircraft Damage: Destroyed
Defining Event: Midair collision
Injuries: 1 Fatal
Flight Conducted Under:  Part 91: General Aviation - Personal

Analysis 

The pilots were making personal flights in the two airplanes, a Luscombe and a Piper, when the airplanes collided in midair in the traffic pattern of the nontowered airport where both airplanes were based. The Luscombe, with a commercial pilot and a passenger onboard departed from runway 17 at the airport, turned left to an east heading, and then left to a north heading, which placed the Luscombe on the downwind leg of the airport traffic pattern. Meanwhile, the Piper with a private pilot aboard approached the airport from the northwest, turned east, and then crossed the airport near midfield about 1,800 ft mean sea level, the airport's traffic pattern altitude. The Piper collided with the Luscombe, and both airplanes entered uncontrolled descents and impacted terrain about a quarter of a mile apart.

Postaccident examination of the wreckage found pieces of the Luscombe with the Piper wreckage and pieces of the Piper with the Luscombe wreckage. Paint and transfer marks on the Luscombe were consistent with the Piper impacting the left rear of the Luscombe.

One pilot-rated witness reported that he saw no indication that either pilot saw the other before the airplanes collided, and the radar data showed no indication of maneuvering to avoid a collision by either airplane. The Luscombe's high-wing configuration and the convergence angle of the airplanes that required the Luscombe pilot to look west into a setting sun to see the Piper likely restricted the Luscombe pilot's ability to see the Piper approaching from his left-rear side. The Piper's low wing configuration may also have restricted the Piper pilot's ability to see the Luscombe that was in front of and likely slightly below him. Further, the Piper pilot's decision to use an alternate traffic pattern entry procedure and cross midfield at traffic pattern altitude rather than at least 500 ft above pattern altitude, which is the preferred traffic pattern entry procedure recommended in Federal Aviation Administration (FAA) guidance material, provided less opportunity for him to see the Luscombe.

Witnesses reported hearing the Luscombe pilot making radio calls on the common traffic advisory frequency (CTAF). They further reported hearing the pilots of other airplanes making calls on the CTAF, but they were not sure if any of the calls were from the Piper pilot. Therefore, it could not be determined if the Piper pilot was making the FAA-recommended traffic pattern entry radio calls.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's use of an alternate traffic pattern entry procedure, which resulted in his inability to see and avoid the other airplane, which was flying the preferred traffic pattern, and the subsequent midair collision. 

Findings

Personnel issues
Monitoring other aircraft - Pilot (Cause)
Use of policy/procedure - Pilot (Cause)

Factual Information

History of Flight

Approach-VFR pattern downwind
Midair collision (Defining event)

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

On December 31, 2016, about 1725 central standard time, a Piper PA-28R-200 airplane, N4407T, and a Luscombe 8A airplane, N2889K, were destroyed when they collided in mid-air over McKinney, Texas, about one-half mile east of the Aero Country Airport (T31), McKinney, Texas. The pilot, the sole occupant onboard the Piper was fatally injured, and the pilot and passenger onboard the Luscombe were also fatally injured. Both airplanes were owned and operated by private individuals. Visual meteorological conditions prevailed at the time of the accident. Both flights were operated under Title 14 Code of Federal Regulations Part 91 as personal flights and were not on flight plans. The Luscombe had departed T31 just prior to the accident, and the Piper was returning to T31.

Several witnesses reported seeing the airplanes, including airplanes being close together prior to the accident and were "in formation", "dog fighting" or "flying tandem together".


A review of radar information revealed the Piper approached the airport from the northwest, before turning east over the airport at an altitude of 1,800 ft mean sea level (msl). A transponder signal was not received from the Luscombe; however, a radar return, consistent with the Luscombe flight path revealed that the airplane departed T31's runway 17, turned east and then headed north, as though in a left downwind traffic pattern. Both airplanes were based at T31.


A video of the accident was captured by a camera mounted in a police cruiser. A review of the video showed both airplanes in the distance. The camera is pointed south and captures the Luscombe near the top center of the image and the Piper enters the frame from the right. The Piper continued toward the Luscombe until they collided. The video then reveals both airplanes spiraling downward in an uncontrolled descent. [photos from the video is included in the docket for this accident] Additionally, a security camera of a nearby business caught part of the Piper's descent, just before impact with the ground.


The Luscombe also had a Go-Pro camera in the cockpit, that was recording during the flight. A review of the Go-Pro video revealed that the camera did not capture the mid-air collision. However, the video did capture images prior to takeoff and during the initial departure. The NTSB's Video Recorders Laboratory technician's report is included in the docket for this accident.


Pilot Information


Certificate: Private

Age: 48
Airplane Rating(s): Single-engine Land
Seat Occupied: Unknown
Other Aircraft Rating(s): None
Restraint Used: Unknown
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 05/25/2016
Occupational Pilot: No
Last Flight Review or Equivalent: 09/24/2016
Flight Time: 815.3 hours (Total, all aircraft) 

The pilot of the Luscombe held a commercial pilot certificate with rating for airplane single-engine and multi-engine land with centerline thrust limitation. The pilot's last medical certificate that was issued on May 22, 2003 as a second class with no limitations. At the time of the exam the pilot listed 325 hours and 6 hours, in the previous 6-months. The pilot was reportedly a former US Air Force pilot; however, investigators did not receive the pilot's total flight time, which would have included his military flight time. The pilot was eligible to fly under the sport pilot medical rules, which requires him to have a valid driver's license.


The pilot of the Piper held a private pilot certificate with ratings for airplane single-engine land and instrument airplane. The pilot's second-class medical certificate was issued on May 25, 2016, with the limitation: must wear corrective lenses. At the time of the exam, the pilot listed 796.7 total hours and 4 hours in the previous 6-months. A review of the pilot's logbook, located in the wreckage, revealed he had a total flight time of 815.3 hours, with the last flight recorded on November 19, 2016. 


Aircraft and Owner/Operator Information


Aircraft Make: PIPER

Registration: N4407T
Model/Series: PA28R 200
Aircraft Category: Airplane
Year of Manufacture: 1972
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 28R-7235089
Landing Gear Type: Retractable - Tricycle
Seats: 4
Date/Type of Last Inspection: 02/01/2016, Annual
Certified Max Gross Wt.:
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 1989.28 Hours as of last inspection
Engine Manufacturer: LYCOMING
ELT: C91  installed, not activated
Engine Model/Series: I0360 SER
Registered Owner: On file
Rated Power: 200 hp
Operator: On file
Operating Certificate(s) Held: None

The Luscombe 8A is a two-seat, high-wing, single-engine airplane, with fixed landing gear. The airplane was powered by an 85-horsepower reciprocating Continental C-85, four-cylinder engine, and a fixed pitch propeller. The airplane was modified with an electrical system including a radio; the airplane was not equipped with a transponder. The airplane qualifies as a light-sport airplane. The last annual inspection was completed on November 25, 2016, at the time of the inspection, the airplane total time was 3,841.43 hours and 485.56 hours since engine overhaul.


The Piper PA28R-200 is a four-seat, low-wing, single-engine airplane, with retractable landing gear. The airplane was powered by a 200-horsepower reciprocating Lycoming IO-360-C1C, four-cylinder engine, and a constant speed propeller. The last annual inspection was completed on February 1, 2016, at the time of the inspection, the airframe and engine had a tachometer time of 1,989.28 hours and 91.28 hours since an engine top overhaul.


Neither airplane was equipped with Automatic Dependent Surveillance-Broadcast (ADS-B), nor were they required to be. Though, the absence of a transponder in the Luscombe was not in compliance with the airspace's mode C vail transponder requirement. 


Meteorological Information and Flight Plan


Conditions at Accident Site: Visual Conditions

Condition of Light: Day
Observation Facility, Elevation: KTKI
Distance from Accident Site: 8 Nautical Miles
Observation Time: 1653 CST
Direction from Accident Site: 90°
Lowest Cloud Condition: Clear
Visibility: 10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 3 knots /
Turbulence Type Forecast/Actual: /
Wind Direction: 200°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 29.76 inches Hg
Temperature/Dew Point: 18°C / 6°C
Precipitation and Obscuration: No Precipitation
Departure Point: McKinney, TX (T31)
Type of Flight Plan Filed: None
Destination:
Type of Clearance: None
Departure Time: CST
Type of Airspace: 

At 1653, the weather observation station located at the McKinney National Airport and about 8 miles east of the accident site recorded: wind from 200° at 3 knots, 10 miles visibility, a clear sky, a temperature of 64° F, dew point 43° F, and an altimeter setting of 29.76 inches of mercury.


Astronomical data from the U.S. Navy Observatory for McKinney, Texas, Collin county, recorded a sunrise at 0730, sunset at 1730, and the end of civil twilight at 1757.


Airport Information

Airport: Aero Country Airport (T31)

Runway Surface Type: 
Airport Elevation: 765 ft
Runway Surface Condition: Dry
Runway Used: 17
IFR Approach: None
Runway Length/Width: 4352 ft / 60 ft
VFR Approach/Landing: Traffic Pattern 

The Aero Country Airport (T31) is a privately owned, open to the public, non-towered airport, located 4 miles west of McKinney, Texas. Pilots are to use the CTAF for communications. T31 has a single asphalt runway oriented 17/35, and 4,352 ft long by 60 ft wide. The airport is at an elevation of 765 ft.


The T31 airport is situated underneath the Dallas-Fort Worth International Airport (DFW), Dallas-Fort Worth, Texas class B airspace, and inside the 30-nautical mile (transponder) mode C vail. 




Wreckage and Impact Information


Crew Injuries: 1 Fatal

Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 33.206667, -96.732778 

The Luscombe impacted a residential street east of the airport and came to rest in a near vertical attitude. Evidence of fuel was present at the accident site, and there was no post-crash fire. The wreckage was removed from the street and was examined. Impact marks and paint/tire transfer marks found on the vertical stabilizer and left rear of the fuselage on the Luscombe were attributed to the Piper. A piece of the Piper wing skin was found among the Luscombe wreckage. The left stabilizer and elevator were missing, and not located during the on-scene portion of the investigation. The stabilizer and elevator were located near a fenced off dumpster and turned over to investigators on February 7, 2017.


The Piper impacted an open concrete area of a storage facility, about one-quarter mile east of the Luscombe. The wreckage was scattered just beyond the initial ground impact point and came to rest near storage lockers. A post-crash fire consumed a portion of the wreckage. Impact and fire damage prevented verification of flight control continuity; however, examination of the flight control cables revealed overload failures and first responder cuts. The landing gear appeared to be extended. Several pieces of unidentified metal skin from the Luscombe were found with the Piper wreckage. 

Communications


Neither pilot was in contact with an air traffic control facility, nor were they required to be. Witnesses reported that they heard the pilot of the Luscombe on the radio CTAF (Common Traffic Advisory Frequency)), recognizing his voice. They added that there were other radio transmissions, but wasn't sure if they were from the Piper pilot or not. 


Medical And Pathological Information


The Office of the Collin County Medical Examiner, McKinney, Texas conducted autopsies on the pilots. The cause of deaths was determined to be: "blunt force injuries".


The Federal Aviation Administration's (FAA) Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, conducted toxicological testing on both pilots. The specimens were not tested for cyanide and carbon monoxide. The tests were negative for ethanol and tested drugs.




Additional Information


Excerpts from FAA Advisory Circular AC 90-66B, Non -Towered Airport Flight Operations


This AC calls attention to regulatory requirements, recommended operations, and communications procedures for operating at an airport without a control tower or an airport with a control tower that operates only part time. It recommends traffic patterns, communications phraseology, and operational procedures for use by aircraft, lighter-than-air aircraft, gliders, parachutes, rotorcraft, and ultralight vehicles.


10.1 Recommended Traffic Advisory Practices. All traffic within a 10-mile radius of a non-towered airport or a part-time-towered airport when the control tower is not operating should continuously monitor and communicate, as appropriate, on the designated CTAF until leaving the area or until clear of the movement area. After first monitoring the frequency for other traffic present passing within 10 miles from the airport, self-announcing of your position and intentions should occur between 8 and 10 miles from the airport upon arrival. Departing aircraft should continuously monitor/communicate on the appropriate frequency from startup, during taxi, and until 10 miles from the airport, unless 14 CFR or local procedures require otherwise.


11 RECOMMENDED STANDARD TRAFFIC PATTERN. The following information is intended to supplement the AIM [Aeronautical Information Manual], paragraph 4-3-3, Traffic Patterns, and the PHAK [ Pilot's Handbook of Aeronautical Knowledge], Chapter 14.


11.3 Traffic Pattern Entry. Arriving aircraft should be at traffic pattern altitude and allow for sufficient time to view the entire traffic pattern before entering. Entries into traffic


patterns while descending may create collision hazards and should be avoided. Entry to the downwind leg should be at a 45-degree angle abeam the midpoint of the runway to be used for landing. The pilot may use discretion to choose an alternate type of entry, especially when intending to cross over midfield, based upon the traffic and communication at the time of arrival.


Note: Aircraft should always enter the pattern at pattern altitude, especially when flying over midfield and entering the downwind directly. A midfield crossing alternate pattern entry should not be used when the pattern is congested. Descending into the traffic pattern can be dangerous, as one aircraft could descend on top of another aircraft already in the pattern. All similar types of aircraft, including those entering on the 45-degree angle to downwind, should be at the same pattern altitude so that it is easier to visually acquire any traffic in the pattern. 


Figure 1. Preferred and Alternate Entry When Crossing Midfield (From the PHAK)


Preferred Entry When Crossing Over Midfield Alternate Midfield Entry


  
N2889K Aviation Accident Final Report - National Transportation Safety Board:  https://app.ntsb.gov/pdf

N2889K Investigation Docket  - National Transportation Safety Board:  https://dms.ntsb.gov/pubdms



N2889K Aviation Accident Data Summary - National Transportation Safety Board:  https://app.ntsb.gov/pdf

http://registry.faa.gov/N2889K 

Location: McKinney, TX
Accident Number: CEN17FA063B
Date & Time: 12/31/2016, 1725 CST
Registration: N2889K
Aircraft: LUSCOMBE 8
Aircraft Damage: Destroyed
Defining Event: Midair collision
Injuries: 2 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal

Analysis 

The pilots were making personal flights in the two airplanes, a Luscombe and a Piper, when the airplanes collided in midair in the traffic pattern of the nontowered airport where both airplanes were based. The Luscombe, with a commercial pilot and a passenger onboard departed from runway 17 at the airport, turned left to an east heading, and then left to a north heading, which placed the Luscombe on the downwind leg of the airport traffic pattern. Meanwhile, the Piper with a private pilot aboard approached the airport from the northwest, turned east, and then crossed the airport near midfield about 1,800 ft mean sea level, the airport's traffic pattern altitude. The Piper collided with the Luscombe, and both airplanes entered uncontrolled descents and impacted terrain about a quarter of a mile apart.

Postaccident examination of the wreckage found pieces of the Luscombe with the Piper wreckage and pieces of the Piper with the Luscombe wreckage. Paint and transfer marks on the Luscombe were consistent with the Piper impacting the left rear of the Luscombe.

One pilot-rated witness reported that he saw no indication that either pilot saw the other before the airplanes collided, and the radar data showed no indication of maneuvering to avoid a collision by either airplane. The Luscombe's high-wing configuration and the convergence angle of the airplanes that required the Luscombe pilot to look west into a setting sun to see the Piper likely restricted the Luscombe pilot's ability to see the Piper approaching from his left-rear side. The Piper's low wing configuration may also have restricted the Piper pilot's ability to see the Luscombe that was in front of and likely slightly below him. Further, the Piper pilot's decision to use an alternate traffic pattern entry procedure and cross midfield at traffic pattern altitude rather than at least 500 ft above pattern altitude, which is the preferred traffic pattern entry procedure recommended in Federal Aviation Administration (FAA) guidance material, provided less opportunity for him to see the Luscombe.

Witnesses reported hearing the Luscombe pilot making radio calls on the common traffic advisory frequency (CTAF). They further reported hearing the pilots of other airplanes making calls on the CTAF, but they were not sure if any of the calls were from the Piper pilot. Therefore, it could not be determined if the Piper pilot was making the FAA-recommended traffic pattern entry radio calls.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The other pilot's use of an alternate traffic pattern entry procedure, which resulted in his inability to see and avoid the airplane, which was flying the preferred traffic pattern, and the subsequent midair collision.

Findings

Personnel issues
Monitoring other aircraft - Pilot of other aircraft (Cause)
Use of policy/procedure - Pilot of other aircraft (Cause)

Factual Information

History of Flight

Approach-VFR pattern downwind
Midair collision (Defining event)

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

On December 31, 2016, about 1725 central standard time, a Piper PA-28R-200 airplane, N4407T, and a Luscombe 8A airplane, N2889K, were destroyed when they collided in mid-air over McKinney, Texas, about one-half mile east of the Aero Country Airport (T31), McKinney, Texas. The pilot, the sole occupant onboard the Piper was fatally injured, and the pilot and passenger onboard the Luscombe were also fatally injured. Both airplanes were owned and operated by private individuals. Visual meteorological conditions prevailed at the time of the accident. Both flights were operated under Title 14 Code of Federal Regulations Part 91 as personal flights and were not on flight plans. The Luscombe had departed T31 just prior to the accident, and the Piper was returning to T31.

Several witnesses reported seeing the airplanes, including airplanes being close together prior to the accident and were "in formation", "dog fighting" or "flying tandem together".

A review of radar information revealed the Piper approached the airport from the northwest, before turning east over the airport at an altitude of 1,800 ft mean sea level (msl). A transponder signal was not received from the Luscombe; however, a radar return, consistent with the Luscombe flight path revealed that the airplane departed T31's runway 17, turned east and then headed north, as though in a left downwind traffic pattern. Both airplanes were based at T31.

A video of the accident was captured by a camera mounted in a police cruiser. A review of the video showed both airplanes in the distance. The camera is pointed south and captures the Luscombe near the top center of the image and the Piper enters the frame from the right. The Piper continued toward the Luscombe until they collided. The video then reveals both airplanes spiraling downward in an uncontrolled descent. [photos from the video is included in the docket for this accident] Additionally, a security camera of a nearby business caught part of the Piper's descent, just before impact with the ground.

The Luscombe also had a Go-Pro camera in the cockpit, that was recording during the flight. A review of the Go-Pro video revealed that the camera did not capture the mid-air collision. However, the video did capture images prior to takeoff and during the initial departure. The NTSB's Video Recorders Laboratory technician's report is included in the docket for this accident.

Pilot Information

Certificate: Commercial
Age: 55
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied:
Other Aircraft Rating(s): None
Restraint Used: Unknown
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Sport Pilot None
Last FAA Medical Exam:
Occupational Pilot: No
Last Flight Review or Equivalent: 
Flight Time: 

The pilot of the Luscombe held a commercial pilot certificate with rating for airplane single-engine and multi-engine land with centerline thrust limitation. The pilot's last medical certificate that was issued on May 22, 2003 as a second class with no limitations. At the time of the exam the pilot listed 325 hours and 6 hours, in the previous 6-months. The pilot was reportedly a former US Air Force pilot; however, investigators did not receive the pilot's total flight time, which would have included his military flight time. The pilot was eligible to fly under the sport pilot medical rules, which requires him to have a valid driver's license.

The pilot of the Piper held a private pilot certificate with ratings for airplane single-engine land and instrument airplane. The pilot's second-class medical certificate was issued on May 25, 2016, with the limitation: must wear corrective lenses. At the time of the exam, the pilot listed 796.7 total hours and 4 hours in the previous 6-months. A review of the pilot's logbook, located in the wreckage, revealed he had a total flight time of 815.3 hours, with the last flight recorded on November 19, 2016.



Aircraft and Owner/Operator Information

Aircraft Make: LUSCOMBE
Registration: N2889K
Model/Series: 8 A
Aircraft Category: Airplane
Year of Manufacture: 1947
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 5616
Landing Gear Type: Tailwheel
Seats: 2
Date/Type of Last Inspection: 11/25/2016, Annual
Certified Max Gross Wt.: 1351 lbs
Time Since Last Inspection:
Engines:  Reciprocating
Airframe Total Time: 3841.43 Hours as of last inspection
Engine Manufacturer: Continental
ELT: C91  installed, not activated
Engine Model/Series: C-85
Registered Owner: On file
Rated Power: 85 hp
Operator: On file
Operating Certificate(s) Held: None 

The Luscombe 8A is a two-seat, high-wing, single-engine airplane, with fixed landing gear. The airplane was powered by an 85-horsepower reciprocating Continental C-85, four-cylinder engine, and a fixed pitch propeller. The airplane was modified with an electrical system including a radio; the airplane was not equipped with a transponder. The airplane qualifies as a light-sport airplane. The last annual inspection was completed on November 25, 2016, at the time of the inspection, the airplane total time was 3,841.43 hours and 485.56 hours since engine overhaul.

The Piper PA28R-200 is a four-seat, low-wing, single-engine airplane, with retractable landing gear. The airplane was powered by a 200-horsepower reciprocating Lycoming IO-360-C1C, four-cylinder engine, and a constant speed propeller. The last annual inspection was completed on February 1, 2016, at the time of the inspection, the airframe and engine had a tachometer time of 1,989.28 hours and 91.28 hours since an engine top overhaul.

Neither airplane was equipped with Automatic Dependent Surveillance-Broadcast (ADS-B), nor were they required to be. Though, the absence of a transponder in the Luscombe was not in compliance with the airspace's mode C vail transponder requirement. 



Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KTKI
Distance from Accident Site: 8 Nautical Miles
Observation Time: 1653 CST
Direction from Accident Site: 90°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 3 knots /
Turbulence Type Forecast/Actual: /
Wind Direction: 200°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 29.76 inches Hg
Temperature/Dew Point: 18°C / 6°C
Precipitation and Obscuration: No Precipitation
Departure Point: McKinney, TX (T31)
Type of Flight Plan Filed: None
Destination: McKinney, TX (T31)
Type of Clearance: None
Departure Time:  CST
Type of Airspace:

At 1653, the weather observation station located at the McKinney National Airport and about 8 miles east of the accident site recorded: wind from 200° at 3 knots, 10 miles visibility, a clear sky, a temperature of 64° F, dew point 43° F, and an altimeter setting of 29.76 inches of mercury.

Astronomical data from the U.S. Navy Observatory for McKinney, Texas, Collin county, recorded a sunrise at 0730, sunset at 1730, and the end of civil twilight at 1757.

Airport Information

Airport: Aero Country Airport (T31)
Runway Surface Type: N/A
Airport Elevation: 765 ft
Runway Surface Condition:
Runway Used: 17
IFR Approach: None
Runway Length/Width: 4352 ft / 60 ft
VFR Approach/Landing: Traffic Pattern 

The Aero Country Airport (T31) is a privately owned, open to the public, non-towered airport, located 4 miles west of McKinney, Texas. Pilots are to use the CTAF for communications. T31 has a single asphalt runway oriented 17/35, and 4,352 ft long by 60 ft wide. The airport is at an elevation of 765 ft.

The T31 airport is situated underneath the Dallas-Fort Worth International Airport (DFW), Dallas-Fort Worth, Texas class B airspace, and inside the 30-nautical mile (transponder) mode C vail. 

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 1 Fatal
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Fatal
Latitude, Longitude: 33.206667, -96.732778 

The Luscombe impacted a residential street east of the airport and came to rest in a near vertical attitude. Evidence of fuel was present at the accident site, and there was no post-crash fire. The wreckage was removed from the street and was examined. Impact marks and paint/tire transfer marks found on the vertical stabilizer and left rear of the fuselage on the Luscombe were attributed to the Piper. A piece of the Piper wing skin was found among the Luscombe wreckage. The left stabilizer and elevator were missing, and not located during the on-scene portion of the investigation. The stabilizer and elevator were located near a fenced off dumpster and turned over to investigators on February 7, 2017.

The Piper impacted an open concrete area of a storage facility, about one-quarter mile east of the Luscombe. The wreckage was scattered just beyond the initial ground impact point and came to rest near storage lockers. A post-crash fire consumed a portion of the wreckage. Impact and fire damage prevented verification of flight control continuity; however, examination of the flight control cables revealed overload failures and first responder cuts. The landing gear appeared to be extended. Several pieces of unidentified metal skin from the Luscombe were found with the Piper wreckage. 

Communications

Neither pilot was in contact with an air traffic control facility, nor were they required to be. Witnesses reported that they heard the pilot of the Luscombe on the radio CTAF (Common Traffic Advisory Frequency)), recognizing his voice. They added that there were other radio transmissions, but wasn't sure if they were from the Piper pilot or not.

Medical And Pathological Information

The Office of the Collin County Medical Examiner, McKinney, Texas conducted autopsies on the pilots. The cause of deaths was determined to be: "blunt force injuries".

The Federal Aviation Administration's (FAA) Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, conducted toxicological testing on both pilots. The specimens were not tested for cyanide and carbon monoxide. The tests were negative for ethanol and tested drugs.

Additional Information

Excerpts from FAA Advisory Circular AC 90-66B, Non -Towered Airport Flight Operations

This AC calls attention to regulatory requirements, recommended operations, and communications procedures for operating at an airport without a control tower or an airport with a control tower that operates only part time. It recommends traffic patterns, communications phraseology, and operational procedures for use by aircraft, lighter-than-air aircraft, gliders, parachutes, rotorcraft, and ultralight vehicles.

10.1 Recommended Traffic Advisory Practices. All traffic within a 10-mile radius of a non-towered airport or a part-time-towered airport when the control tower is not operating should continuously monitor and communicate, as appropriate, on the designated CTAF until leaving the area or until clear of the movement area. After first monitoring the frequency for other traffic present passing within 10 miles from the airport, self-announcing of your position and intentions should occur between 8 and 10 miles from the airport upon arrival. Departing aircraft should continuously monitor/communicate on the appropriate frequency from startup, during taxi, and until 10 miles from the airport, unless 14 CFR or local procedures require otherwise.

11 RECOMMENDED STANDARD TRAFFIC PATTERN. The following information is intended to supplement the AIM [Aeronautical Information Manual], paragraph 4-3-3, Traffic Patterns, and the PHAK [ Pilot's Handbook of Aeronautical Knowledge], Chapter 14.

11.3 Traffic Pattern Entry. Arriving aircraft should be at traffic pattern altitude and allow for sufficient time to view the entire traffic pattern before entering. Entries into traffic

patterns while descending may create collision hazards and should be avoided. Entry to the downwind leg should be at a 45-degree angle abeam the midpoint of the runway to be used for landing. The pilot may use discretion to choose an alternate type of entry, especially when intending to cross over midfield, based upon the traffic and communication at the time of arrival.

Note: Aircraft should always enter the pattern at pattern altitude, especially when flying over midfield and entering the downwind directly. A midfield crossing alternate pattern entry should not be used when the pattern is congested. Descending into the traffic pattern can be dangerous, as one aircraft could descend on top of another aircraft already in the pattern. All similar types of aircraft, including those entering on the 45-degree angle to downwind, should be at the same pattern altitude so that it is easier to visually acquire any traffic in the pattern.