Tuesday, December 18, 2018

Mitsubishi MU-2B-40 Solitaire, owned by private individuals and operated by the pilot, N73MA: Fatal accident occurred September 23, 2017 near Ainsworth Regional Airport (KANW), Brown County, Nebraska

Dr. Robert George Cook

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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Lincoln, Nebraska
Mitsubishi Heavy Industries; Addison, Texas
Honeywell Aerospace; Phoenix, Arizona 
Honeywell Product Integrity; Olathe, Kansas
Hartzell Propeller; Piqua, Ohio

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

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

http://registry.faa.gov/N73MA

Location: Ainsworth, NE
Accident Number: CEN17FA362
Date & Time: 09/23/2017, 1028 CDT
Registration: N73MA
Aircraft: MITSUBISHI MU 2B-40
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

On September 23, 2017, about 1028 central daylight time, a Mitsubishi MU 2B-40 airplane, N73MA, was destroyed when it impacted terrain 3.5 miles northeast of the Ainsworth Regional Airport (ANW), Ainsworth, Nebraska. The private pilot was fatally injured. The airplane was owned by private individuals and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91. Instrument meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan had been filed for the flight; however, it had not been activated. The personal flight was originating at the time of the accident and was en route to Bottineau Municipal Airport (D09), Bottineau, North Dakota.

According to Federal Aviation Administration (FAA) records and the pilot's cellular telephone records, the pilot contacted the Flight Service Station (FSS) in Fort Worth, Texas, about 1015 on the morning of the accident to file an IFR flight plan. The pilot stated that he was en route to D09 and requested an altitude of 16,000 ft. The FSS specialist offered to provide adverse weather and route of flight information; the pilot declined.

There were no other telephone calls made to FAA air traffic control (ATC) facilities or FSS, from the pilot's telephone, before the accident. Several notices to airman (NOTAMS) were issued for ANW and were valid on the day of the accident. Specifically, the hazardous inflight weather advisory service outlet and the remote communications outlet on frequencies 122.4 and 121.5 were out of service.

According to the ANW airport manager, the airplane was fueled in a hangar just before the flight because it was raining. The airport manager was in the fixed base operator (FBO) building when he heard the start of both engines; everything sounded normal. He watched the airplane depart from runway 35 (6,824 ft by 110 ft; asphalt) and enter the clouds.

Several witnesses in the area reported hearing an airplane flying from the southwest to the northeast. One witness located north of ANW characterized the sound as if the airplane was lower than usual or buzzing the ground. One witness stated that the visibility was low and that the engines sounded "wound up really tight, full throttle, and very loud." The witness heard a "thud" as he was walking into his house and asked his wife if anything had fallen in the house to which she responded no; he attributed the noise to a thunderstorm in the vicinity.

According to the pilot's family, he was flying to D09 to pick up a dog, who had been at a training camp all summer. He planned to meet a friend, who was training his dog, at D09 around 1200. The airplane was reported missing by the friend of the pilot when the airplane did not arrive at D09 as scheduled. The wreckage was located about 1800.

A search of ATC radar data did not find any primary or secondary radar targets consistent with the accident airplane. The "low altitude radar" was not operational in the area of ANW on the day of the accident. The airplane's exact route of flight after takeoff could not be established. 

Dr. Robert Cook (simply Dr. Bob to most)

Pilot Information

Certificate: Private
Age: 69, Male
Airplane Rating(s): Multi-engine Land; Multi-engine Sea; 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 3 With Waivers/Limitations
Last FAA Medical Exam: 05/09/2016
Occupational Pilot: No
Last Flight Review or Equivalent: 06/03/2017
Flight Time: (Estimated) 3775 hours (Total, all aircraft), 2850 hours (Total, this make and model)

At the time of medical certificate application, the pilot reported no chronic medical conditions and no medications. The pilot was issued a medical certificate that contained the limitation "must wear corrective lenses for near and distant vision."

The pilot's flight logbook was not located during the investigation. The co-owner of the airplane stated that he had co-owned several MU-2 airplanes with the pilot since 2000, and he estimated that the pilot had logged 2,500 hours in the make and model of the accident airplane. According to the pilot's application for medical certificate, dated May 9, 2016, he estimated his total pilot time was 3,775 hours; 64 of which were logged in the previous 6 months.

According to records provided by SIMCOM Aviation Training, the pilot had completed initial Mitsubishi MU-2B training at Flight Safety in 1999. The pilot's most recent recurrent training was completed on June 3, 2017, at SIMCOM. The pilot also successfully completed an instrument proficiency check at that time. The instrument training included a simulated partial panel instrument landing system (ILS) approach. At the time of the most recent recurrent course, the pilot estimated his time on the prerequisite form as 2,850 hours in MU-2B airplanes.

Aircraft and Owner/Operator Information

Aircraft Make: MITSUBISHI
Registration: N73MA
Model/Series: MU 2B-40 26A
Aircraft Category: Airplane
Year of Manufacture: 1979
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 414 SA
Landing Gear Type: Retractable - Tricycle
Seats: 7
Date/Type of Last Inspection: 09/05/2017, 100 Hour
Certified Max Gross Wt.: 10470 lbs
Time Since Last Inspection: Engines: 2 Turbo Prop
Airframe Total Time: 5383.6 Hours as of last inspection
Engine Manufacturer: Honeywell
ELT: C91A installed, not activated
Engine Model/Series: TPE331
Registered Owner: On file
Rated Power:
Operator: On file
Operating Certificate(s) Held: None 

A flight log for the accident airplane, located in the wreckage and dated September 22, 2017, showed the airplane cycles at 1,125, and the hobbs at takeoff as 13,850.0 hours. The hobbs landing and flight time fields were not populated on the form. The departure airport was Kenosha Regional Airport (ENW), Kenosha, Wisconsin, and the destination was ANW.

According to a photograph of the instrument panel provided by the co-owner, the airplane was equipped with a two-screen Chelton Air Data Attitude Heading Reference System (ADAHRS) display in place of the standard 6 primary flight instruments on the pilot-side of the instrument panel. Below the two-screen Chelton display, from left to right, the pilot had an attitude indicator and a turn and slip indicator. A second attitude indicator was mounted on the co-pilot's side of the instrument panel, on the upper right corner. 

Meteorological Information and Flight Plan

Conditions at Accident Site: Instrument Conditions
Condition of Light: Day
Observation Facility, Elevation: KANW, 2588 ft msl
Distance from Accident Site: 3 Nautical Miles
Observation Time: 1035 CDT
Direction from Accident Site: 209°
Lowest Cloud Condition:
Visibility:  1.75 Miles
Lowest Ceiling: Overcast / 500 ft agl
Visibility (RVR):
Wind Speed/Gusts: 10 knots /
Turbulence Type Forecast/Actual: None / None
Wind Direction: 360°
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 30.01 inches Hg
Temperature/Dew Point: 9°C / 9°C
Precipitation and Obscuration: Mist; No Precipitation
Departure Point: Ainsworth, NE (KANW)
Type of Flight Plan Filed: IFR
Destination: Bottineau, ND (D09)
Type of Clearance: None
Departure Time: 1028 CDT
Type of Airspace: Class E

A weather study was conducted by the National Transportation Safety Board in support of this accident investigation and the detailed weather study is available in the public docket.

The National Weather Service Surface (NWS) Surface Analysis Chart for 1000 CDT depicted a low-pressure system and an associated stationary front south of the accident site, with the accident site in an area of favorable overrunning conditions for low cloud development. The station models in the vicinity of the accident site, north of the front, indicated northerly winds of 5 to 10 knots, overcast cloud cover, and restricted visibility in fog or mist.

A review of the NWS Composite Reflectivity image taken at 1025 CDT depicted several strong to intense cells between 59 and 75 miles to the east-northeast of ANW and the accident site with no significant echoes in the immediate vicinity of the accident site. The Geostationary Operational Environmental Satellite depicted two bands of clouds with a radiative cloud top temperature consistent with 24,000 ft; the bands were on either side of the accident site. Low stratiform clouds were over the accident site.

The ANW weather observation taken at 1015 CDT reported wind from 360° at 10 knots, visibility 1 3/4 miles in mist, ceiling overcast at 500 ft agl. Temperature 10° Celsius (C), dew point temperature 10 C, and altimeter 30.02 inches of mercury. Similar conditions continued to be reported.

A Convective SIGMET for an area of embedded thunderstorms, a Center Weather Advisory for an area of heavy rain showers, and AIRMET Sierra for an extensive area of IFR conditions, were indicated for the route of flight.

Airport Information

Airport: Ainsworth Regional (KANW)
Runway Surface Type: Asphalt
Airport Elevation: 2588 ft
Runway Surface Condition:
Runway Used: 35
IFR Approach: None
Runway Length/Width: 6824 ft / 110 ft
VFR Approach/Landing: None

Ainsworth Regional Airport is a public, non-towered airport (Class E airspace) located 6 miles northwest of Ainsworth, Nebraska., at a surveyed elevation of 2,588 ft. The airport had 2 open asphalt runways; runway 17/35 (6,824 ft by 110 ft) and runway 13/31 (5,501 ft by 1,677 ft by 73 ft). Four area navigation (RNAV) (GPS) approaches and 2 VHF omnidirectional range (VOR) approaches were available. Special takeoff minimums of 1 statute mile visibility and obstacles departure procedures due to a fence near the departure end of runway 31 were in place. 

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 42.536944, -99.959167 

The wreckage came to rest in a grazing pasture vegetated with tall grass. The accident site was at an elevation of 2,590 ft msl, and the debris and wreckage path were oriented on a magnetic heading of 270°.

Torn and fragmented remains of the left wing tip tank were located in the initial impact crater. The crater was about 3 ft deep, 10 ft wide, and 8 ft long. A long narrow ground scar extended from the initial impact crater west 6 ft to a second crater. The scar was about 3 ft at its widest point and about 1 ft deep.

The second crater was about 25 ft long, 20 ft at its widest point, and 6 ft deep. The second crater contained the left engine and left propeller assembly. The assembly exhibited signatures consistent with exposure to heat and fire. Two propeller blades separated from the propeller assembly and were embedded in the crater. The outboard 6 inches of two blades separated and were located north of the crater. The crater also contained torn and fragmented metal consistent with the left wing and fuselage, engine tubing and components, and the counter weight for the left horizontal stabilizer.

The right engine was located at the west end of the crater and was embedded in the ground.

A ground scar extended 6 ft west to a third crater. The crater was about 3 ft deep, 8 ft long, and 7 ft at its widest point. The crater contained fragmented metal, tubing, and components. The debris field continued from the third crater west about 23 ft to the main piece of wreckage.

The left main landing gear assembly was located 12 ft north of the main wreckage. The landing gear actuator position was consistent with the landing gear being retracted. The right main landing gear was with the main wreckage.

The main wreckage included flight control cables, electrical wiring, tubing, the vertical stabilizer, rudder, and center and left side of the wing.

Cabin seats, electrical wiring cables, and torn and fragmented metal extended farther west from the main wreckage. The farthest component was located about 280 ft southwest of the wreckage on the adjacent dirt farm road. The right elevator separated and was located 4 ft west of the main piece of wreckage. The right flap was separated and located about 10 ft farther west. The control cables were broken in multiple locations and continuity could not be confirmed. Separated cable ends illustrated broomstraw signatures consistent with overload separation due to impact forces. The fuselage was fragmented. The wing flaps were set at zero based upon the actuator position and was consistent with damage signatures on the cockpit flap selector.

The scope of the examination was limited by fragmentation due to impact damage; however, no anomalies consistent with a preimpact failure or malfunction were observed. 

Medical And Pathological Information

The Nebraska Institute of Forensic Sciences, Inc. performed the autopsy on the pilot on September 26, 2017, as authorized by Brown County Nebraska. The autopsy concluded that the cause of death was "multiple blunt force trauma," and the report listed the specific injuries. There was no evidence of recent medical intervention or natural disease that could pose a hazard to flight safety.

The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological tests on specimens that were collected during the pilot's autopsy. Carbon monoxide and cyanide tests were not performed. Results were negative for tested drugs. Testing of the liver revealed 12 mg/dL ethanol; however, no ethanol was detected in the muscle tissue. When ethanol is ingested, it is quickly distributed throughout the body's tissues and fluids fairly uniformly. Ethanol may also be produced in the body after death by microbial activity.

Additional Information

Chelton Air Data Attitude Heading Reference System (ADAHRS)

A Chelton ADAHRS was installed on the airplane in October of 2008 in accordance with the Chelton Flight Systems supplemental type certificate (STC) SA02203AK. During a flight from Kenosha, Wisconsin, to LaCross, Wisconsin, on the Wednesday before the accident, the pilot encountered a "transient flag" on the Chelton ADAHRS and mentioned it to the co-owner of the airplane. The pilot planned to take the airplane in for avionics work to follow-up on this issue the next week.

The owners of the airplane had avionics work completed at May Day Avionics in Grand Rapids, Michigan; there was no work done on the avionics immediately before the accident flight. According to a manager at May Day Avionics, the pilot left a voice mail on or around September 21 (2 days before the accident), regarding a transient flag he received on the unit. The voicemail stated that the flag was related to ADAHRS, but no further detail was provided. The manager did not speak directly with the pilot about the flag before the accident and could not provide any further details regarding the issue.

The Chelton Flight Systems Manual, Section 3, addresses "Failure Modes" for the system. There are potentially 6 modes with an ADAHRS failure mode or flag. Without further details regarding this transient flag the pilot encountered, it is not possible to factually discuss the impact this failure would have on the information displayed for the pilot. It is not known if the pilot had an issue with the Chelton system at the time of the accident.

The Chelton ADAHRS was fragmented in the accident and could not be functionally tested.

Wreckage Examination

The airplane wreckage was recovered and relocated to a secure facility for further examination.

The right engine exhibited extensive impact damage and was fragmented. Rotational scoring was present on the impeller blades and shroud. The first stage impeller was impact separated and all blades were separated along the hub at the root. The third stage blades were intact and exhibited metal spray. The right engine accessories were impact damaged and separated and could not be functionally tested.

The left engine exhibited extensive impact damage and was fragmented. The first stage impeller was impact damaged and all but two blades separated. The blades of the second stage impeller were bent opposite the direction of rotation with heavy wear signatures. The third stage blades were impact damaged, bent, and exhibited "heavy rub" signatures and metal spray deposits. The left engine accessories were impact damaged and separated and could not be functionally tested.

The left propeller assembly separated from the engine at the propeller flange. Three of the four blades from the left propeller assembly separated. Impact marks in the hydraulic units were consistent with a blade pitch between 26° and 60°. The blades were bowed and twisted and exhibited chordwise/rotational scoring, leading edge polishing, and gouges. The tips of two blades were impact separated.

The right propeller assembly separated from the engine at the propeller flange. Three of the four blades from the right propeller assembly separated. The blades were bowed and twisted and exhibited chordwise/rotational scoring, leading edge polishing, and gouges. The tip of one blade was impact separated.

The damage to both propeller assemblies was similar and symmetric, and the damage to the blades was consistent with ground impact while the engine was producing power and the propeller blades were producing thrust. No anomalies were noted that would have precluded normal operations.

Spatial Disorientation

The FAA Civil Aeromedical Institute's publication, "Introduction to Aviation Physiology," defines spatial disorientation as a loss of proper bearings or a state of mental confusion as to position, location, or movement relative to the position of the earth. Factors contributing to spatial disorientation include changes in acceleration, flight in IMC, frequent transfer between visual meteorological conditions (VMC) and IMC, and unperceived changes in aircraft attitude.

The FAA's Airplane Flying Handbook (FAA-H-8083-3A) describes some hazards associated with flying when the ground or horizon are obscured. The handbook states, in part:

"The vestibular sense (motion sensing by the inner ear) in particular tends to confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in the attitude of the airplane, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated; leading the pilot to believe the attitude of the airplane has changed when in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation."

Nieuport 28, registered to C C Air Corporation and operated by the pilot, N6190: Fatal accident occurred April 23, 2017 in Paso Robles, San Luis Obispo County, California

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

Additional Participating Entity:

Federal Aviation Administration / Flight Standards District Office; San Jose, California

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


Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms
 
http://registry.faa.gov/N6190



Location: Paso Robles, CA
Accident Number: WPR17FA089
Date & Time: 04/23/2017, 0912 PDT
Registration: N6190
Aircraft: APPLEBY NIEUPORT 28
Aircraft Damage: Substantial
Defining Event: Loss of control in flight
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

On April 23, 2017, about 0912 Pacific daylight time, an experimental amateur-built Nieuport 28 biplane, N6190, sustained substantial damage when it impacted terrain about 4 miles east of Paso Robles Municipal Airport (PRB), Paso Robles, California. The airline transport pilot was fatally injured. The airplane was registered to C C Air Corporation and was being operated by the pilot under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. Visual meteorological conditions prevailed, and no flight plan had been filed. The local personal flight departed from Bonel Airport (95CA), Whitney Garden, California, about 0907.

A witness located about 1 mile south of 95CA, heard the airplane take off, observed the airplane turn left to the cross-wind leg of the traffic pattern, and then observed it turn left again to the downwind leg of the traffic pattern. Another witness located about 1/2 mile west of the accident site, reported observing the airplane in a steep nose-down attitude just before it impacted the ground.


Pilot Information

Certificate: Airline Transport
Age: 54, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land; Single-engine Sea
Seat Occupied: Front
Other Aircraft Rating(s): Glider
Restraint Used: 4-point
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): Airplane Multi-engine; Airplane Single-engine
Toxicology Performed: Yes
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 05/20/2014
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time:  (Estimated) 7170 hours (Total, all aircraft) 

The pilot, age 54, held an airline transport pilot certificate with ratings for airplane multi-engine land and single-engine land, airplane single-engine sea, and glider. He also held a flight instructor certificate with airplane single-engine, multi-engine, and instrument ratings. The pilot's most recent third-class Federal Aviation Administration (FAA) airman medical certificate was issued on May 20, 2014, with the limitation to have available glasses for near vision. The pilot reported on the application for that medical certificate that he had accumulated 7,170 total hours of flight experience, of which 100 hours were in the previous 6 months.

The pilot's logbooks were not located during the investigation. 


Aircraft and Owner/Operator Information

Aircraft Make: APPLEBY
Registration: N6190
Model/Series: NIEUPORT 28 NO SERIES
Aircraft Category: Airplane
Year of Manufacture: 1976
Amateur Built: Yes
Airworthiness Certificate: Experimental
Serial Number: AA102
Landing Gear Type: Skid;
Seats: 1
Date/Type of Last Inspection: 04/05/2017, Condition
Certified Max Gross Wt.: 1600 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 348.9 Hours as of last inspection
Engine Manufacturer: Gnome
ELT: Not installed
Engine Model/Series: 9-N
Registered Owner: On file
Rated Power: 160 hp
Operator: On file
Operating Certificate(s) Held: None 

The single-seat, fixed-gear biplane, was a World War I fighter replica, that was built in 1976 and acquired by the pilot in 1993. It was powered by a 160-horsepower, reciprocating, rotary Gnome 9-N, engine. The engine was equipped with a fixed pitch Falcon Manufacturing model 160-Gnome, propeller. 

A review of the airframe logbook revealed that all maintenance and inspections had been accomplished by the same airframe and powerplant mechanic since the pilot acquired the airplane. An entry dated March 30, 1994, at an airframe time of 318 hours, indicated that the airframe was stripped, inspected, cleaned, painted, and a 160 horsepower Gnome engine was installed. On November 8, 1995, at 95CA, the airplane was disassembled for shipment. On November 29, 1995, at 95CA, the airplane was reassembled and inspected, and certified for flight. On March 23, 2016, at an airframe total time of 345.9 hours, the airplane's fabric covering was replaced, and the airplane was subsequently painted. The most recent condition inspection was completed on April 5, 2017, at an airframe total time of 348.9 hours.

The logbook indicated that the airplane was flown 5 times in 2016 for a total time of 3 hours. No flights were logged in 2017. No elevator or elevator control cable maintenance was documented in the airplane's logbook.


Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: PRB, 838 ft msl
Distance from Accident Site: 5 Nautical Miles
Observation Time: 0853 PDT
Direction from Accident Site: 90°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 9 knots /
Turbulence Type Forecast/Actual: /
Wind Direction: 320°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 29.99 inches Hg
Temperature/Dew Point: 13°C / 8°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: WHITLEY GARDEN, CA (95CA)
Type of Flight Plan Filed: None
Destination: WHITLEY GARDEN, CA (95CA)
Type of Clearance: None
Departure Time: 0907 PDT
Type of Airspace: Class G

At 0853, the recorded weather conditions at PRB were wind from 320° at 9 knots, visibility 10 miles, sky clear, temperature 13° C, dew point 8° C, and an altimeter setting of 29.99 inches of mercury.

Airport Information

Airport: BONEL (95CA)
Runway Surface Type: N/A
Airport Elevation: 1030 ft
Runway Surface Condition: Vegetation
Runway Used: 17
IFR Approach: None
Runway Length/Width: 2000 ft / 50 ft
VFR Approach/Landing: Traffic Pattern

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 35.669167, -120.548611 (est) 

Examination of the accident site by the National Transportation Safety Board (NTSB) investigator-in-charge and an FAA inspector revealed that the airplane impacted the ground in a flat wheat field at an elevation of about 1,055 ft mean sea level. All the major components of the airplane were located at the accident site. The first identified point of contact was an area of disturbed dirt that measured about 2 ft long, 3 ft wide, and 12 inches deep, in which the airplane's propeller was embedded. Wreckage debris was confirmed to an area within about 10 ft of the main wreckage. The airplane's bank and pitch angles at impact were estimated to be about 30° left-wing-down and about 80° nose-down respectively.

The fuselage came to rest inverted on a heading of about 145° magnetic, and it was displaced to the left and folded over the top of the upper left wing, which was embedded in the terrain. Fuel was observed leaking near the center of the wreckage.

The upper and lower left wings were partially attached, oriented nearly parallel to the fuselage, and sustained leading-edge compression damage throughout their wing spans. The left aileron was attached at all its respective points and sustained damage to the outboard third. The left main wheel and attachments had separated, and a 4-inch section of the wheel was crushed inward.

The upper and lower right wings remained partially attached to the main fuselage and had sustained damage about mid-span and leading-edge compression damage throughout their wing spans. The right aileron was attached at all its respective points. The right main wheel was observed to be relatively intact. 

The main cockpit area sustained severe impact damage. Several flight instruments had separated from the instrument panel. The tachometer displayed an engine rpm of about 2,040 rpm and the airspeed indicator indicated about 87 mph. The empennage and fuselage aft of the cockpit area, was relatively intact. The rudder and elevators remained attached. 

Flight control continuity was established to the ailerons and rudder. The elevator control cable that resulted in the elevator trailing-edge down movement was intact, and the control cable that resulted in elevator trailing-edge up movement was found disconnected at its turnbuckle connection located within the belly of the airplane. No evidence of any safety wire or safety clips was observed on either end of the turnbuckle assembly. The end of the turnbuckle where the rod end should have been connected was undamaged, and the threads on the rod end and within the barrel of the turnbuckle were undamaged. All remaining turnbuckles throughout the airplane's flight control system were safety wired.

The engine was embedded into the ground about at the impact angle. Both magnetos remained attached, and several engine accessories were separated. Both wood propeller blades were buried in the dirt. One blade separated near the hub, and the other blade was separated and splintered about mid-span. Examination of the engine revealed no evidence of any mechanical malfunction or failure that would have precluded normal operation. 

Medical And Pathological Information

The San Luis Obispo County Coroner's Office, San Luis Obispo, California, conducted an autopsy on the pilot. The medical examiner determined that the cause of death was blunt force trauma.

The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing on the pilot. The results for the testing were negative for carbon monoxide, cyanide, volatiles, and all tested for drugs.

Additional Information

According to FAA regulations, experimental airplanes are required to receive a conditional inspection every 12 months that is to be performed by an airframe and powerplant mechanic in accordance with 14 CFR Part 43, Appendix D. Appendix D outlines requirements in part, to inspect all systems and components for improper installation, apparent defects, and unsatisfactory operation. Flight and engine controls are to be inspected for improper installation and improper operation. Further, all systems are to be inspected for improper installation, poor general condition, apparent and obvious defects, and insecurity of attachment.

According to the mechanic, who performed the maintenance on the airplane, the flight control cables and turnbuckle assemblies that were contained in the interior section of the airplane's fuselage (including the section of elevator cable that was found disconnected) were not accessible during routine or condition inspections. A window in the empennage allowed for inspections of the elevator control attachments only in the tail, and the rudder control attachments could be inspected externally. The mechanic stated that even when the fuselage's fabric skin was removed, the entire flight control cables and turnbuckle assemblies in the belly were not readily accessible to be observed because of the plywood paneling and wood stringers in the area.

FAA Advisory Circular 43.13B, Acceptable Methods, Techniques, and Practices – Aircraft Inspection and Repair, Chapter 10, Paragraph 7-179 states "safety all turnbuckles with safety wire using either the double or single wrap, or with any appropriately approved special safetying device complying with the requirements of FAA Technical Standard Order TSO-C21."

Lost of Control in Flight: Piper PA-28R-200 Arrow, N4504X; fatal accident occurred February 12, 2017 in Cedar Key, Florida



Pilot Logbook Excerpts 


Maintenance Logbook Excerpts 


Global Positioning System Device









Weather Study

 Jasper Jerrels’ 17-year-old son, Dylan.

Jasper Jerrels, 65 and his fiancée Hue Pham Singletary, 65.


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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Tampa, Florida
Piper Aircraft; Vero Beach, Florida
Lycoming Engines; Williamsport, Pennsylvania

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


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


http://registry.faa.gov/N4504X 



Location: Cedar Key, FL
Accident Number: ERA17FA108
Date & Time: 02/12/2017, 1106 EST
Registration: N4504X
Aircraft: PIPER PA28R
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight
Injuries: 3 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal

Analysis 

The non-instrument rated private pilot departed in the airplane in visual meteorological conditions, which prevailed along most of the route of the over-water cross-country flight. However, about 20 miles from the destination airport, the airplane encountered an area of instrument meteorological conditions (IMC) that consisted of overcast clouds with bases about 400 ft above the water. According to GPS data, when the airplane reached this area, it began to descend from a cruising altitude of 2,400 ft. About 7 minutes later, at an altitude of about 1,000 ft, the airplane began a left, descending, 180° turn during which the altitude fluctuated until the data ended about 600 ft above the water near the accident site. The airplane continued to descend until it impacted the water. Examination of the wreckage did not reveal any evidence of preimpact mechanical malfunctions that would have precluded normal operation. The pilot had logged only 4.6 hours of simulated instrument experience and had no documented actual instrument experience. No evidence was found indicating that the pilot obtained an official weather briefing before the flight. If he had obtained such a briefing, he would have been told that visual flight rules (VFR) flight was not recommended due to IMC near the destination airport. Given the instrument conditions in the destination area and the pilot's limited instrument flying experience, it is likely that the pilot attempted to continue VFR flight into IMC, experienced spatial disorientation, and lost control of the airplane. 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The non-instrument-rated pilot's improper decision to continue visual flight rules flight into instrument meteorological conditions, which resulted in spatial disorientation and a loss of airplane control. 

Findings

Aircraft
Performance/control parameters - Not attained/maintained (Cause)

Personnel issues
Decision making/judgment - Pilot (Cause)
Spatial disorientation - Pilot (Cause)
Aircraft control - Pilot (Cause)
Total instrument experience - Pilot (Cause)

Environmental issues
Low ceiling - Decision related to condition (Cause)
Below VFR minima - Decision related to condition (Cause)
Below VFR minima - Ability to respond/compensate (Cause)

Factual Information

History of Flight

Enroute-descent
Loss of control in flight (Defining event)

Uncontrolled descent

Collision with terr/obj (non-CFIT)

On February 12, 2017, about 1106 eastern standard time, a Piper PA-28R-200, N4504X, was destroyed when it impacted the Gulf of Mexico about 7 miles southeast of Cedar Key, Florida. The private pilot and two passengers were fatally injured. The airplane was registered to Flying Arrow, LLC and was being operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91. Instrument meteorological conditions prevailed in the area of the accident site, and no flight plan was filed for the personal flight. The flight departed Brooksville-Tampa Bay Regional Airport (BKV), Brooksville, Florida, at 1037, destined for George T. Lewis Airport (CDK), Cedar Key, Florida.

According to GPS data recovered from a handheld device onboard the airplane, the airplane flew a northwesterly track from BKV toward CDK at a cruising altitude of about 2,400 ft mean sea level (msl) over coastal islands and the Gulf of Mexico. Review of the GPS track and satellite imagery indicated that about 20 nautical miles southeast of CDK, the airplane began to gradually descend near a line of overcast cloud cover that ran from southwest to northeast. Weather data from the closest available reporting stations and from pilot reports indicated that the cloud bases decreased in height from south to north. About 3 minutes later, the airplane's descent rate increased to about 250 ft per minute (fpm) as the airplane continued its northwesterly track. About 4 minutes later, when the airplane was about 7 nautical miles from CDK at an altitude of about 1,000 ft msl, the airplane began a descending left 180° turn. During the turn, the vertical speed varied, and the airplane began a brief climb before descending again at a rate of about 2,900 fpm; the recorded data ended at an altitude of about 570 ft msl. 

Pilot Information

Certificate: Private
Age: 65, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: Unknown
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: 02/19/2015
Occupational Pilot: No
Last Flight Review or Equivalent: 08/13/2016
Flight Time:  (Estimated) 606 hours (Total, all aircraft), 300 hours (Total, this make and model), 3 hours (Last 90 days, all aircraft) 

According to Federal Aviation Administration (FAA) airmen records, the pilot held a private pilot certificate with a rating for airplane single-engine land. He did not possess an instrument rating. His most recent FAA third-class medical certificate was issued February 19, 2015, at which time he reported 579 total hours of flight experience. According to his logbook, as of January 28, 2017, he had accrued a total of 606 hours of flight experience that included 3 hours in the 90 days preceding the accident. He had logged a total of 4.6 hours of simulated instrument flight time of which the most recent was 0.3 hour during his last flight review performed on August 13, 2016, in the accident airplane.



Aircraft and Owner/Operator Information

Aircraft Make: PIPER
Registration: N4504X
Model/Series: PA28R 200
Aircraft Category: Airplane
Year of Manufacture: 1975
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 28R-7635065
Landing Gear Type: Retractable - Tricycle
Seats: 4
Date/Type of Last Inspection: 05/01/2016, Annual
Certified Max Gross Wt.: 2600 lbs
Time Since Last Inspection: 14 Hours
Engines: 1 Reciprocating
Airframe Total Time: 2806.2 Hours as of last inspection
Engine Manufacturer: Lycoming
ELT: C91  installed, not activated
Engine Model/Series: IO-360-C1C
Registered Owner: FLYING ARROW LLC
Rated Power: 200 hp
Operator: FLYING ARROW LLC
Operating Certificate(s) Held: None

According to FAA records, the airplane was manufactured in 1975. It was equipped with a fuel-injected, horizontally-opposed four-cylinder, direct-drive, air-cooled Lycoming IO-360-C1C engine. Damaged portions of the maintenance logbook were found inside the airplane. The most recent annual inspection was completed May 1, 2016, at 2,806 total airframe hours. The airplane had accrued 14 hours since that date. The engine total time and time since overhaul could not be determined from the logbook remnants.



Meteorological Information and Flight Plan

Conditions at Accident Site: Instrument Conditions
Condition of Light: Day
Observation Facility, Elevation: KCTY, 42 ft msl
Distance from Accident Site: 36 Nautical Miles
Observation Time: 1055 EST
Direction from Accident Site: 348°
Lowest Cloud Condition:
Visibility:  10 Miles
Lowest Ceiling: Overcast / 400 ft agl
Visibility (RVR):
Wind Speed/Gusts: 5 knots /
Turbulence Type Forecast/Actual: None / None
Wind Direction: 240°
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 30.25 inches Hg
Temperature/Dew Point: 19°C / 18°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: BROOKSVILLE, FL (BKV)
Type of Flight Plan Filed: None
Destination: CEDAR KEY, FL (CDK)
Type of Clearance: None
Departure Time: 1037 EST
Type of Airspace: Class G 

There was no record of the pilot obtaining an official weather briefing from flight service or via direct user access terminal.

The Cross City Airport (CTY), Cross City, Florida, located about 36 miles north of the accident site, was the nearest weather reporting station. At 1055, the reported weather at CTY included an overcast ceiling at 400 ft above ground level (agl) with a visibility of 10 miles. Atmospheric models and data from other nearby stations indicated that the conditions at the accident site included fog and low stratus cloud cover up to about 4,000 ft agl. The weather reported for the airplane's route of flight south of the accident location indicated visual meteorological conditions with clear skies below 12,000 ft agl and visibility greater than 5 miles.

The National Weather Service issued an area forecast at 0648 for northern Florida that advised to expect scattered to broken clouds at 1,000 ft agl with visibility 3 miles in mist and scattered clouds at 1,500 ft were expected by 1100. The forecast for the eastern panhandle of Florida included overcast clouds at 1,000 ft agl with visibility 3 miles in mist. Advisories issued at the time of this forecast warned of instrument meteorological conditions at and near the accident site and the destination airport. 

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 2 Fatal
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 3 Fatal
Latitude, Longitude: 29.049167, -82.968056 (est) 

The airplane was recovered from the Gulf of Mexico and moved to a secure facility for examination. All major components of the airplane were accounted for except for a large section of the left wing that included the left main landing gear. Flight control continuity was established from the cockpit area through recovery cuts to the attach points on the rudder, stabilator, and stabilator trim jackscrew. Aileron control continuity was established from the cockpit area through overload fractures to the right aileron pushrod and to the root area of the left wing. The right main and nose landing gears were found in the retracted position. The flaps were not recovered; however, the left rod end of the flap torque tube was found in the forward position, consistent with a fully retracted position.

The engine was separated from the airframe. The propeller remained attached to the engine crankshaft flange, and the spinner was crushed against the hub. Two of the propeller blades exhibited longitudinal twisting. The third blade was bent aft about 180° and exhibited leading edge gouging at a distance from the hub consistent with impact damage found on the No. 2 engine cylinder.

The engine was rotated by hand at the propeller, and crankshaft continuity was observed to the rear accessory section. Valve action was observed at each cylinder, and thumb compression and suction were present on cylinders Nos. 1 and 3. Cylinder No. 2 was significantly damaged and exhibited an impact mark consistent with a strike from a propeller blade. A damaged spark plug precluded compression testing of cylinder No. 4. Neither magneto produced spark when rotated by hand. Internal examination of both magnetos revealed that sand, water, and corrosion were present. The vacuum pump remained attached to the engine; the drive coupling, carbon rotor, and carbon vanes were intact. 

Medical And Pathological Information


The Office of the Medical Examiner, District 8, Gainesville, Florida, performed an autopsy on the pilot. The cause of death was listed as massive injuries.

The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing on the pilot. Results were positive for pioglitazone and sitagliptin, which are used treat type 2 diabetes and to lower blood sugar levels, respectively. In general, neither of these medications are considered to be impairing.