Sunday, July 14, 2019

Loss of Control in Flight: Zenith 601 XL, N105JT; accident occurred October 22, 2018 near Freeman Field Airport (3JC), Junction City, Geary County, Kansas

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; 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

https://registry.faa.gov/N105JT

Location: Junction City, KS
Accident Number: GAA19CA037
Date & Time: 10/22/2018, 1830 CDT
Registration: N105JT
Aircraft: Zenith CH601
Aircraft Damage: Substantial
Defining Event: Loss of control in flight
Injuries: 1 None
Flight Conducted Under: Part 91: General Aviation - Personal 

The pilot in the experimental amateur-built airplane reported that about 5 minutes after takeoff, he felt air coming into the cockpit from the canopy. He noticed that the canopy latch was not adequately secured and attempted to secure it, but the canopy opened. The airplane became very difficult to control with the canopy open and he made an emergency landing in a cornfield. During landing, the nose wheel collapsed, and the airplane skidded to a stop.

The airplane sustained substantial damage to the fuselage.

The pilot reported that there were no mechanical malfunctions or failures with the airplane that would have precluded normal operation. 

Pilot Information

Certificate: Private
Age: 67, 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: No
Medical Certification: None With Waivers/Limitations
Last FAA Medical Exam: 08/01/2004
Occupational Pilot: No
Last Flight Review or Equivalent: 06/26/2018
Flight Time:  (Estimated) 223 hours (Total, all aircraft), 15 hours (Total, this make and model), 160 hours (Pilot In Command, all aircraft), 9 hours (Last 90 days, all aircraft) 

Aircraft and Owner/Operator Information

Aircraft Make: Zenith
Registration: N105JT
Model/Series: CH601 XL
Aircraft Category: Airplane
Year of Manufacture: 2006
Amateur Built: Yes
Airworthiness Certificate: Experimental
Serial Number: 6-5291
Landing Gear Type: Tricycle
Seats: 2
Date/Type of Last Inspection: 07/01/2017, Condition
Certified Max Gross Wt.: 1320 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 124.2 Hours at time of accident
Engine Manufacturer: Jabiru
ELT: Installed, not activated
Engine Model/Series: 3300A
Registered Owner: On file
Rated Power: 120 hp
Operator: On file
Operating Certificate(s) Held: None 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KFRI, 1065 ft msl
Distance from Accident Site: 4 Nautical Miles
Observation Time: 2356 UTC
Direction from Accident Site: 84°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 4 knots /
Turbulence Type Forecast/Actual:
Wind Direction: 30°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 30.12 inches Hg
Temperature/Dew Point: 16°C / 10°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Junction City, KS (3JC)
Type of Flight Plan Filed: None
Destination: Junction City, KS (3JC)
Type of Clearance: None
Departure Time: 1830 CDT
Type of Airspace: Class E

Airport Information

Airport: FREEMAN FIELD (3JC)
Runway Surface Type: Dirt; Grass/turf
Airport Elevation: 1101 ft
Runway Surface Condition: Dry; Vegetation
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: Full Stop; Precautionary Landing 

Wreckage and Impact Information

Crew Injuries: 1 None
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 None
Latitude, Longitude: 39.043333, -96.843333 (est)

Loss of Engine Power (Total): Beech B36TC Bonanza, N6860W; accident occurred August 20, 2018 near La Porte Municipal Airport (T41), Harris County, Texas

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

Additional Participating Entity:

Federal Aviation Administration / Flight Standards District Office; Houston, Texas

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/N6860W



Location: LaPorte, TX
Accident Number: CEN18LA340
Date & Time: 08/20/2018, 0620 CDT
Registration: N6860W
Aircraft: BEECH B36TC
Aircraft Damage: Destroyed
Defining Event: Loss of engine power (total)
Injuries: 1 None
Flight Conducted Under: Part 91: General Aviation - Personal 

On August 20, 2018, at 0620 central daylight time, a Beech B36TC single-engine airplane, N6860W, was destroyed when the engine lost power and the pilot made a forced landing in a wooded area 1/4-mile southeast of La Porte Municipal Airport (T41), La Porte, Texas. The airplane was registered to and operated by RD Airways, Channelview, Texas, under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. Visual meteorological conditions prevailed at the time of the accident, and no flight plan had been filed for local flight. The flight was originating from T41 at the time of the accident.

The pilot reported that after taking off and starting a climb, the airplane began to make a "weird very loud sound and the engine started to lose power." The pilot verified the throttle, mixture, and propeller controls were full forward. The engine noise "started getting louder and power was almost gone." When the pilot activated the auxiliary fuel pump, the engine "just got real loud and sounded very deep. I knew I was descending." The airplane continued to descend, and the pilot made a forced landing near a housing development on unsuitable terrain. Both wings were separated from the airplane. The pilot was not injured.

A Federal Aviation Administration (FAA) inspector examined the airplane, and reported "the exhaust section looks like it had been having some issues for a while. Also disturbing is the v-band clamp condition." He also stated an Airworthiness Directive (A.D. 2018-06-11) had been issued in June 2018. That AD added a life limit to the exhaust tailpipe v-band clamp that attaches the exhaust tailpipe to the turbocharger and requires an annual visual inspection of the exhaust tailpipe v-band coupling (clamp).

The engine was sent to Continental Motors, Mobile, Alabama, where, on March 13, 2019, it was functionally tested under the oversight of an FAA inspector. The engine performed with no anomalies. According to Continental Motors, the v-band may have been loose enough to allow manual rotation of the turbo outlet collar. A hose used to connect the aftermarket intercooler was oil-soaked and did not appear to be freshly torn. If the hose failed in flight, manifold pressure would have immediately dropped and the "weird" sound could have been turbo discharge pressure escaping through the tear. When the engine lost turbo pressure, the fuel pump would have continued to operate with a much richer mixture, not sensing the loss of induction pressure to the engine. When the pilot turned on the auxiliary fuel pump, the engine would have been further flooded with excess fuel pressure.



Pilot Information

Certificate: Student
Age: 39, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s):None 
Toxicology Performed: No
Medical Certification: Class 3 Without Waivers/Limitations
Last FAA Medical Exam: 09/14/2017
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time:  63 hours (Total, all aircraft), 20 hours (Total, this make and model), 13 hours (Pilot In Command, all aircraft)



Aircraft and Owner/Operator Information

Aircraft Make: BEECH
Registration: N6860W
Model/Series: B36TC
Aircraft Category: Airplane
Year of Manufacture: 1984
Amateur Built: No
Airworthiness Certificate: Normal; Utility
Serial Number: EA-411
Landing Gear Type: Retractable - Tricycle
Seats: 5
Date/Type of Last Inspection: 03/23/2018, Annual
Certified Max Gross Wt.: 3850 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 3103 Hours as of last inspection
Engine Manufacturer: Continental
ELT: Installed, not activated
Engine Model/Series: TSIO-520UB12B
Registered Owner: On file
Rated Power: 300 hp
Operator: On file
Operating Certificate(s) Held: None 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Dawn
Observation Facility, Elevation: EFD, 32 ft msl
Distance from Accident Site: 7 Nautical Miles
Observation Time: 0650 CDT
Direction from Accident Site: 225°
Lowest Cloud Condition: Few / 2000 ft agl
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 4 knots /
Turbulence Type Forecast/Actual:
Wind Direction: 170°
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 30 inches Hg
Temperature/Dew Point: 26°C / 26°C
Precipitation and Obscuration:
Departure Point: La Porte, TX (T41)
Type of Flight Plan Filed: None
Destination: La Porte, TX (T41)
Type of Clearance: None
Departure Time: 0620 CDT
Type of Airspace: Class G 

Airport Information

Airport: La Porte Municipal (T41)
Runway Surface Type: Asphalt
Airport Elevation: 25 ft
Runway Surface Condition: Dry
Runway Used: 12
IFR Approach: None
Runway Length/Width: 4165 ft / 75 ft
VFR Approach/Landing: Forced Landing

Wreckage and Impact Information

Crew Injuries: 1 None
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 None
Latitude, Longitude:  29.672500, -95.069722

Loss of Engine Power (Total): Cessna 172L Skyhawk, N2893Q; fatal accident occurred August 16, 2018 near Rhome Meadows Airport (T76), Wise County, Texas

Curtis Scott Moore
December 11th, 1954 – August 16th, 2018
~

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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Irving, Texas
Lycoming Engines; Texas
Textron Aviation; Wichita, Kansas

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


http://registry.faa.gov/N2893Q


Location: Rhome, TX
Accident Number: CEN18FA336
Date & Time: 08/16/2018, 1935 CDT
Registration: N2893Q
Aircraft: Cessna 172
Aircraft Damage: Substantial
Defining Event: Loss of engine power (total)
Injuries: 1 Fatal, 3 Serious
Flight Conducted Under: Part 91: General Aviation - Personal 

On August 16, 2018, about 1935 central daylight time, a Cessna 172L airplane, N2893Q, impacted trees and terrain shortly after departure from Rhome Meadows Airport (T76), Rhome, Texas. The commercial pilot was fatally injured and the three passengers sustained serious injuries. The airplane sustained substantial damage. The airplane was registered to and operated by the pilot as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. Visual meteorological conditions prevailed at the time of the accident and no flight plan had been filed. The local flight was departing T76 at the time of the accident.

A family member stated that the pilot retrieved the airplane from under the open-air shelter for "family fun night" and was giving rides to several family members. The family members stated that the pilot had flown the airplane about one week before the accident, then again two times immediately preceding the accident flight. The two preceding flights lasted about 20 minutes and 10 minutes respectively and the family members reported no anomalies with the airplane. They also stated that during the accident flight the airplane departed from the grass runway and did not gain much altitude before it banked hard to the left and then descended behind a tree line. Figure 1 represents a satellite map view of T76 and the accident location.

Figure 1. Overhead map view of airport and accident area

A pilot-rated witness reported that he saw the airplane depart T76 and then land soon after. The airplane taxied back and three passengers boarded with the engine still running. He stated that the airplane taxied back to the runway and started the takeoff roll, during which the engine did not sound like it was developing full power. The takeoff roll was longer than he expected, and once the airplane was airborne, the nose pitched up "very high" to about 50 ft above ground level (agl), then the nose came back down. The airplane flew low over the runway and appeared to accelerate until it pitched up and climbed to about 300 ft agl. The airplane then made a left turn and descended out of view.


Curtis Scott Moore

Pilot Information

Certificate: Commercial
Age: 63, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Right
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 2 With Waivers/Limitations
Last FAA Medical Exam: 10/13/2017
Occupational Pilot: Yes
Last Flight Review or Equivalent:
Flight Time:  (Estimated) 8000 hours (Total, all aircraft) 

On his most recent second-class medical certificate application, dated October 13, 2017, the pilot reported 8,000 total hours of flight experience and 125 hours in the preceding 6 months. The pilot's wife stated that he did not log his recent flight time and had not recorded flights in his pilot logbook since the 1990s.

During the flight, the pilot was seated in the front right seat with a minor in the front left seat; an adult and minor were seated on the rear bench seat. 



Aircraft and Owner/Operator Information

Aircraft Make: Cessna
Registration: N2893Q
Model/Series: 172 L
Aircraft Category: Airplane
Year of Manufacture: 1971
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 17259893
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection:  Unknown
Certified Max Gross Wt.: 2299 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time:
Engine Manufacturer: Lycoming
ELT: C91A installed, not activated
Engine Model/Series: O-320-E2D
Registered Owner: On file
Rated Power: 150 hp
Operator: On file
Operating Certificate(s) Held: None 

The pilot's wife stated that the airplane's maintenance logbooks were never received from the previous owner after the airplane was purchased in 2013. There was no documentation of maintenance performed since that time and no evidence that the airplane had received an annual inspection. A representative for the previous owner could not find the logbooks.

Family members stated that fuel cans, which were filled at another airport, were typically used to refill the airplane; those fuel cans were used to fuel the airplane on the night of the accident. The fuel cans were filled at an unknown time the week before the accident. 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Dusk
Observation Facility, Elevation: KLUD, 1047 ft msl
Distance from Accident Site: 8 Nautical Miles
Observation Time: 1735 CDT
Direction from Accident Site: 324°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 3 knots /
Turbulence Type Forecast/Actual:
Wind Direction: 150°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 29.97 inches Hg
Temperature/Dew Point: 34°C / 19°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Rhome, TX (T76)
Type of Flight Plan Filed: None
Destination: Rhome, TX (T76)
Type of Clearance: None
Departure Time: 1935 CDT
Type of Airspace: Class E 

Airport Information

Airport: Rhome Meadows (T76)
Runway Surface Type: Grass/turf
Airport Elevation: 900 ft
Runway Surface Condition: Dry
Runway Used: 13
IFR Approach: None
Runway Length/Width: 3700 ft / 60 ft
VFR Approach/Landing: None 

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries: 3 Serious
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal, 3 Serious
Latitude, Longitude: 33.148056, -97.490000

The airplane came to rest inverted on a southeast heading about 350 yards north of the departure end of runway 13 (see figure 2).

Figure 2. Airplane inverted in a field

A postaccident examination of the accident site and wreckage revealed that the left wing leading edge was crushed aft and sustained impact damage, including evidence of tree strikes; the wing was partially separated from the fuselage and distorted aft. The right wing leading edge was crushed aft. All flight control cables were traced from their respective control surfaces to the cockpit controls with no separations or anomalies noted. The elevator trim tab was slightly nose-down but near neutral. The flaps were retracted. The right control yoke was separated at the control column, consistent with impact damage. The left control yoke was damaged consistent with impact.

There were no shoulder harnesses installed. The adult passenger reported that all occupants wore lap belts during the flight, and all four lap belts appeared to exhibit stretching in the webbing, indicative of the belts being worn during impact. The right rear lap belt was found separated from the eyelet at the floorboard. The left front seat was improperly safety-wired.

The fuel selector handle and valve were found in the OFF position; first responders reported that they moved the handle to OFF after the accident. A small amount of fuel was found in the firewall fuel strainer. The fuel was tested for water using water-detecting paste; the test was negative. The left and right wing fuel tanks were impact damaged, but about 2 gallons of fuel were drained from the tanks during the recovery process.

Two empty beer cans were found in the front left floorboard area near the rudder pedals. A rodent's nest was found inside the left wing near an area that had been impact damaged. A significant amount of cobwebs were observed in the engine compartment. The airbox was clear of obstructions. A large mud dauber nest was found on the fins of the oil cooler. The ELT was found in place with battery acid residue on the outside of the case. An automotive battery was installed in the airplane.

The tip of the propeller spinner was bent but the rest of the spinner was mostly undamaged. The 2 propeller blades were straight and undamaged with no chordwise scratches or leading edge damage.

The gascolator fuel strainer was disassembled and organic debris similar to insect cocoons was found inside the strainer screen (see figure 3). The strainer bowl was mostly full of blue-colored fuel consistent with 100LL aviation gasoline.

Figure 3. Fuel fitting with organic contaminants

The main fuel line from the gascolator to the carburetor was a hydraulic hose manufactured in July 2013 and featured a Department of Transportation marking consistent with an automotive hydraulic hose.

Engine crankshaft and camshaft continuity was confirmed by manually rotating the propeller. Thumb suction and compression was obtained for each cylinder. Normal rocker and valve movement was observed and all accessory gears rotated at the back of the engine. The exhaust system sustained damage to the heat exchanger, which was breached as a result of the accident. All of the flame cones were deteriorated and missing.

The carburetor was removed and disassembled; the float chamber contained about 5 mL of fuel. The fuel was tested for water using water-detecting paste; the test was negative. Both magnetos were secure on their respective mounts. The ignition timing was verified at 25° before top dead center on the left magneto. The left magneto was actuated by rotating the propeller by hand, it produced spark at all outlet points. The right magneto was secure on its mount. The ignition timing was verified about 30° before top dead center. The right magneto was removed from its mount and rotated using an electric drill, it produced spark at all outlet points. The top spark plugs were removed and exhibited a color consistent with normal combustion. The oil filter did not display any information regarding the last time it was changed. 




Medical And Pathological Information

Southwestern Institute of Forensic Sciences, Dallas, Texas, completed an autopsy on the pilot and determined the cause of death was "blunt force injuries." The autopsy discovered evidence of hypertensive and atherosclerotic cardiovascular disease, including cardiomegaly, left ventricular hypertrophy, a fusiform aneurysm in the right coronary artery, and moderate atherosclerosis of two other coronary arteries.

Toxicology testing performed by the FAA Forensic Sciences Laboratory identified ethanol in subclavian blood, vitreous fluid, and urine (0.154 gm/dL, 0.177 gm/dL, and 0.194 gm/dL respectively); and 0.0033 µg/mL of delta-9-tetrahydrocannabinol (THC) in the blood. THC's active metabolite, 11-hydroxy-delta-9-THC, was not detected, but the inactive metabolite, carboxy-delta-9-THC, was detected at 0.0139 µg/mL. Both THC metabolites were detected in urine; 11-hydroxy-delta-9-THC at 0.0094 µg/mL and carboxy-delta-9-THC at 0.0346 µg/mL.

Ethanol is a social drug commonly consumed by drinking beer, wine, or liquor. Ethanol acts as a central nervous system depressant; it impairs judgment, psychomotor functioning, and vigilance. Effects of ethanol on aviators are generally well understood; it significantly impairs pilots' performance, even at very low levels. Title 14 CFR Section 91.17 (a) prohibits any person from acting or attempting to act as a crewmember of a civil aircraft while having 0.040 gm/dL or more ethanol in the blood. Ethanol is water soluble, and after absorption it quickly and uniformly distributes throughout the body's tissues and fluids. The distribution pattern parallels water content and blood supply of the tissue. A small amount of ethanol can be produced after death by microbial activity, usually in conjunction with other alcohols such as methanol; vitreous humor and urine do not suffer from such production. Postabsorption, vitreous humor has about 12% more ethanol than blood and urine about 25% more ethanol than blood.

THC is the primary psychoactive substance in marijuana, which is listed as a schedule I controlled substance. THC's mood-altering effects include euphoria, relaxed inhibitions, disorientation, image distortion, and psychosis. THC is stored in fatty tissues and can be released back into the blood long after consumption. While the psychoactive effects may last for a few hours, THC may be detected in the blood for days or weeks. Low THC levels of a few nanograms per milliliter in blood can result from relatively recent use (e.g., smoking within 1 to 3 hours) when some slight or even moderate impairment is likely to be present, or it can result from chronic use where no recent ingestion has occurred and no impairment is present. Thus, the level of THC in the blood and level of impairment do not appear to be closely related. See the NTSB Medical Factual Report in the public docket for additional information and references.

Runway Excursion: Aero Commander S-2R, N5521X; accident occurred August 15, 2018 at Rolling Hills Airport (3MN4), Westbrook, Cottonwood County, Minnesota

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

Additional Participating Entity:

Federal Aviation Administration / Flight Standards District Office; Minneapolis, Minnesota

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/N5521X

Location: Westbrook, MN
Accident Number: CEN18LA332
Date & Time: 08/15/2018, 1145 CDT
Registration: N5521X
Aircraft: AERO COMMANDER S2R
Aircraft Damage: Substantial
Defining Event: Runway excursion
Injuries: 1 Minor
Flight Conducted Under: Part 137: Agricultural 

On August 15, 2018, about 1145 central daylight time, an Aero Commander S2R, N5521X, was substantially damaged during a runway excursion on takeoff from runway 9 at the Rolling Hills Airport (3MN4), Westbrook, Minnesota. The operator stated that the airplane did not climb as expected after takeoff and it encountered a corn field off the end of the runway. The pilot was not injured. The airplane was registered to and operated by Olsem Aerial Application Service as a Title 14 Code of Federal Regulations Part 137 flight. Day visual meteorological conditions prevailed. The local flight was not operated on a flight plan. The flight was originating at the time of the accident.

The pilot informed a Federal Aviation Administration (FAA) inspector that he had experienced a loss of engine power at rotation during takeoff. The pilot reported that there were two small rises along the turf runway. The airplane normally became airborne at the second rise. The accident takeoff proceeded normally past the first rise. However, as the airplane approached the second rise, the tail of the airplane dropped to the ground. The pilot perceived a loss of engine power and began to drop the application load immediately afterward. The operator stated that the airplane was fueled before the accident flight and was within the maximum gross weight limitation at the time of the accident.

The airstrip was oriented east-west and the accident takeoff was preformed toward the east. A soybean field was located immediately off the end of the runway, followed by a two-lane roadway, and a corn field. The soybean field exhibited evidence of the application load being dropped as the airplane passed over but appeared to be otherwise undisturbed. The airplane continued across the intervening two-lane roadway and traveled about 300 ft into the corn field, leveling the existing 8-foot corn crop, before nosing over and coming to rest. A postaccident examination conducted by FAA inspectors did not reveal any anomalies consistent with a loss of engine power or a failure or malfunction of the flight control system.

The airplane was equipped with an engine monitor unit which was recovered from the wreckage and downloaded. A review of the data indicated that the accident takeoff was the fifth of the day. The data revealed a momentary exceedance of the interstage turbine temperature (ITT) on the initial engine start of the day consistent with a hot start event. Otherwise, the engine parameters appeared to be within normal operating limits during the previous flights. The engine was not shutdown between flights.

The data revealed that, at the beginning of the accident takeoff, the engine speed increased smoothly from an idle speed of about 64% to 99% over a period of 5 seconds, and it remained at or above 97% for the remainder of the takeoff run. The fuel flow and oil pressure increased in conjunction with the engine speed. The engine torque increased in conjunction with the engine speed and subsequently stabilized at 100% about 35 seconds later. Each of the noted parameters stabilized within normal operating limitations during the takeoff run and were consistent with the engine operating normally at full takeoff power. About 50 seconds after the takeoff began, the engine speed and torque parameters decayed abruptly. The engine speed decreased from 98.3% to zero over a 4-second time interval. The engine torque increased momentarily to 106% before decreasing to zero over the following 3-second interval. The abrupt decrease in engine speed and torque was consistent with the encounter with the corn field. 

Pilot Information

Certificate: Commercial
Age: 46, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Single
Other Aircraft Rating(s): None
Restraint Used: 4-point
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 02/28/2018
Occupational Pilot: Yes
Last Flight Review or Equivalent:
Flight Time: 5600 hours (Total, all aircraft) 

Aircraft and Owner/Operator Information

Aircraft Make: AERO COMMANDER
Registration: N5521X
Model/Series: S2R
Aircraft Category: Airplane
Year of Manufacture: 1973
Amateur Built: No
Airworthiness Certificate: Restricted
Serial Number: 1721R
Landing Gear Type: Tailwheel
Seats: 1
Date/Type of Last Inspection:  Annual
Certified Max Gross Wt.:
Time Since Last Inspection:
Engines:  Turbo Prop
Airframe Total Time:
Engine Manufacturer: Honeywell
ELT: Not installed
Engine Model/Series: TPE-331-6
Registered Owner: Olsem Aerial Application Service
Rated Power: 750 hp
Operator: Olsem Aerial Application Service
Operating Certificate(s) Held: Agricultural Aircraft (137)

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: MWM, 1411 ft msl
Distance from Accident Site: 13 Nautical Miles
Observation Time: 1135 CDT
Direction from Accident Site: 90°
Lowest Cloud Condition: Scattered / 1600 ft agl
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 6 knots /
Turbulence Type Forecast/Actual:
Wind Direction: 360°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 29.97 inches Hg
Temperature/Dew Point: 25°C / 20°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Westbrook, MN (3MN4)
Type of Flight Plan Filed: None
Destination: Westbrook, MN (3MN4)
Type of Clearance: None
Departure Time: 1145 CDT
Type of Airspace: Class G

Airport Information

Airport: Rolling Hills (3MN4)
Runway Surface Type: Grass/turf
Airport Elevation: 1477 ft
Runway Surface Condition: Dry
Runway Used: 9
IFR Approach: None
Runway Length/Width: 2250 ft / 60 ft
VFR Approach/Landing: None

Wreckage and Impact Information

Crew Injuries: 1 Minor
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Minor
Latitude, Longitude: 43.950833, -95.378333 (est)

Loss of Engine Power (Partial): Cessna 188 AgWagon, N5523S; accident occurred August 02, 2018 in Watkins, Minnesota

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

Additional Participating Entity:

Federal Aviation Administration / Flight Standards District Office; Minneapolis, Minnesota

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/N5523S




Location: Watkins, MN
Accident Number: CEN18LA311
Date & Time: 08/02/2018, 1035 CDT
Registration: N5523S
Aircraft: Cessna 188
Aircraft Damage: Substantial
Defining Event: Loss of engine power (partial)
Injuries: 1 None
Flight Conducted Under: Part 137: Agricultural 

On August 2, 2018, about 1035 central daylight time, a Cessna 188 airplane, N5523S, was substantially damaged during a forced landing following a partial loss of engine power near Watkins, Minnesota. The pilot was not injured. The airplane was registered to a private individual and operated by Classic Arrow Inc. as a Title 14 Code of Federal Regulations Part 137 agricultural application flight. Day visual meteorological conditions prevailed. The flight was not operated on a flight plan. The local flight originated from the Litchfield Municipal Airport (LJF), Litchfield, Minnesota, about 0945.

The pilot reported that the airplane was fully fueled before the flight. After takeoff, he flew about 20 minutes to the field to be sprayed. He proceeded to survey for hazards and completed a few spray passes. He subsequently noted a loss of engine speed (rpm) after completing an application pass. He pushed the propeller control forward in an attempt to increase the engine/propeller speed which was successful for a short period of time. However, the engine speed began to decrease again, and he observed a decrease in oil pressure combined with an increase in the oil temperature. He moved all engine controls – throttle, propeller, and mixture – full forward. As he returned for a forced landing to the corn field being sprayed, the oil pressure was about 7 psi. As the airplane came over the field, the engine was "coughing." After impacting the corn, the airplane "angled up on the nose" before coming to rest. He recalled the weather conditions as "very good," with a light wind, clear sky, and more than 10 miles visibility.

The pilot informed a Federal Aviation Administration (FAA) inspector that the loss of engine power was not catastrophic in nature. Rather, the pilot observed the oil pressure dropping with the oil temperature rising and decided to pull the mixture to shut the engine off. He subsequently landed in the corn field just below the airplane.

The FAA inspector reported that the airplane sustained substantial damage to the right wing. Postaccident airframe and engine examinations conducted by the inspector revealed no anomalies that could be attributed to a preimpact failure or malfunction. 



Pilot Information

Certificate: Commercial
Age: 21, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Single
Other Aircraft Rating(s): None
Restraint Used: 4-point
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 1 Without Waivers/Limitations
Last FAA Medical Exam: 05/11/2018
Occupational Pilot: Yes
Last Flight Review or Equivalent: 
Flight Time:  566 hours (Total, all aircraft), 124 hours (Total, this make and model)

Aircraft and Owner/Operator Information

Aircraft Make: Cessna
Registration: N5523S
Model/Series: 188 Undesignated
Aircraft Category: Airplane
Year of Manufacture: 1966
Amateur Built: No
Airworthiness Certificate: Restricted
Serial Number: 188-0023
Landing Gear Type: Tailwheel
Seats: 1
Date/Type of Last Inspection: 02/14/2018, Annual
Certified Max Gross Wt.:
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 2700 Hours as of last inspection
Engine Manufacturer: Continental
ELT: Not installed
Engine Model/Series: O-470-R
Registered Owner: On file
Rated Power: 230 hp
Operator: On file
Operating Certificate(s) Held: Agricultural Aircraft (137)
Operator Does Business As: Classic Arrow Inc.
Operator Designator Code: 6MTG 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: LJF, 1140 ft msl
Distance from Accident Site: 14 Nautical Miles
Observation Time: 1035 CDT
Direction from Accident Site: 200°
Lowest Cloud Condition:
Visibility:  10 Miles
Lowest Ceiling: Broken / 3300 ft agl
Visibility (RVR):
Wind Speed/Gusts: 3 knots /
Turbulence Type Forecast/Actual:
Wind Direction: 70°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 30.06 inches Hg
Temperature/Dew Point: 18°C / 13°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Litchfield, MN (LJF)
Type of Flight Plan Filed: None
Destination: Litchfield, MN (LJF)
Type of Clearance: None
Departure Time: 0945 CDT
Type of Airspace: Class G

Airport Information

Airport: Litchfield Muni (LJF)
Runway Surface Type: N/A
Airport Elevation: 1140 ft
Runway Surface Condition: Vegetation
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: Forced Landing 

Wreckage and Impact Information

Crew Injuries: 1 None
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 None
Latitude, Longitude: 46.814167, -94.408611 (est)

Propeller Contact with Person: Cessna 182P Skylane, N1311S; fatal accident occurred July 26, 2018 at Cleveland Regional Jetport (KRZR), Bradley County, Tennessee



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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Nashville, Tennessee
Federal Aviation Administration / Manufacturing and Inspection District Office; Phoenix, Arizona
Federal Aviation Administration / Aircraft Certification Office; 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

http://registry.faa.gov/N1311S



Location: Cleveland, TN
Accident Number: ERA18LA199
Date & Time: 07/26/2018, 1648 EDT
Registration: N1311S
Aircraft: Cessna 182
Aircraft Damage: None
Defining Event: AC/prop/rotor contact w person
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal

HISTORY OF FLIGHT

On July 26, 2018, about 1648 eastern daylight time, the private pilot of a Cessna 182P, N1311S, was fatally injured when he was struck by the propeller during a preflight inspection of the airplane at the Cleveland Regional Jetport (RZR), Cleveland, Tennessee. The airplane, which was not damaged, was owned by NCFL Ltd., and privately operated under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. Visual meteorological conditions prevailed for the intended personal flight to Blairsville Airport (DZJ), Blairsville, Georgia.

The pilot's wife reported that they had flown to RZR earlier that day, and her husband performed a normal shutdown of the engine utilizing the mixture control. They performed errands then returned to the airport. While outside the airplane behind the passenger door facing her seat, her husband was performing a preflight inspection of the airplane with the airplane's ignition key in his pocket. She heard the "propeller move" which she described as unusual and heard the engine like it was starting or trying to start. She looked up and noticed her husband fall to the ground. She went to him and thought the propeller stopped at that time, then went inside the fixed-base-operator to summon help.

According to FAA and airport personnel, airport security video did not capture the sequence of events.



AIRCRAFT INFORMATION

Airplane History

The four-place, high-wing airplane, serial number 18264876, was manufactured in 1976. It was powered by a 230-hp Continental O-470-S engine equipped with two independent engine-driven magnetos electrically controlled by an on-condition, key actuated, five position rotary ignition switch mounted on the lower left portion of the pilot's instrument panel.

The pilot purchased the airplane in April 2007, and it remained in his operational control the entire time. According to the pilot's wife, since then, there was no previous instance in which the ignition key could be removed from the switch in an intermediate position, or any position other than the off position. She also indicated that since owning the airplane, there was no previous issue of the key coming out, falling out, or being loose.

Cessna Service Bulletin SEB91-5 Revision 1, dated June 14, 1991, applicable to the accident make and model airplane by serial number and also by the installed ignition switch, specified an inspection and lubrication of the ignition switch; however, there was no requirement to determine if the key could be removed from any position other than off.

Review of the airplane service manual that describes inspection procedures at 50 Hours, 100 Hours, 200 Hours, and special inspection items, and review of 14 CFR Part 43 Appendix D which documents the scope and detail of items to be inspected in the annual or 100-hour inspections revealed no specific mention to check if the key could be removed from any position other than off.

A review of the Pilot's Operating Handbook that documents the preflight inspection items revealed a requirement to verify the ignition switch being in the off position before beginning the outside inspection. The inspection of the propeller specifies to check for nicks, security and oil leaks.

Airworthiness Directive (AD) 93-05-06, applicable to ACS Products Company and Gerdes Products Company ignition switches and the accident make and model airplane by serial number, specified an internal inspection for corrosion, lubrication of the ignition switch, and to determine if a diode or other surge suppresser was installed on the starter solenoid. The AD was required to be completed within 100 hours after the effective date of the AD (April 29, 1993), or at the next annual inspection, whichever occurred first. The AD did not specify a test to determine key to switch integrity, or to determine if the key could be removed from any position other than off. The maintenance records reflect that the AD was originally signed off as being completed on July 27, 1993, at airframe total time of 2,880.7 hours. The next compliance with the AD as part of an annual inspection was on January 10, 2018, at airframe total time 4,895 hours. Based on pilot records excluding the flight earlier that day, the airplane had been operated about 31 hours since the inspection was performed. There was no entry in the airframe maintenance records dating to manufacture indicating replacement of the ignition switch or key.

The mechanic who performed the annual inspection and complied with AD 93-05-06 indicated that he also installed new internal ignition switch contacts and terminal board supplied in kit A3650-2. He also reportedly checked the ignition key to switch integrity in all switch positions other than off reporting no discrepancies. Additionally, as part of his procedures, while the engine was running, he slightly pulled aft on the key to see if it could be removed from any position and also in between positions. The key did not come out in any position other than off.



Postaccident Airplane and Ignition Switch Examination

Examination of the cockpit by representatives of the FAA revealed that the mixture control was in the idle-cutoff position, the throttle was full out, the battery and alternator rocker switches were each in the off position. From the pilot's perspective, the ignition switch appeared to be in the off position; however, on closer inspection the ignition switch was more toward the right magneto position. The ignition switch was photographed and then after installation of the ignition key, the switch was able to be turned counterclockwise to the OFF position. The inspector also noted that the ignition key was easily removable from the ignition switch in the right and left positions. Subsequent testing of the ignition system was performed by a mechanic with FAA oversight. The ignition switch was marked where found (between the off and right positions), and in that position, the right magneto was hot, or not grounded, and the key could be fully removed from the ignition switch that was tightly secured to the instrument panel. When in the off position, the switch did not align with the instrument panel placard marking. The airplane's ignition switch and key were then removed and sent to the FAA for operational testing at the manufacturer's facility with FAA oversight.

Examination of the Gerdes Products Company ignition switch (Model No. A-510, Cessna part number (P/N) C292501-0105) and key were performed at ACS Products Company. The switch was manufactured in April 1976, and there was no record of it being returned to either Gerdes or ACS since being manufactured as neither company repairs switches after delivery. The switch testing was performed using the current procedure for a A-510-2 Ignition Switch (With start), which required verification in part that the key could not be removed in any position other than off. The examination revealed that the key was removable in every position (left, right, both, start, and off). In the as-found position which was marked, testing verified the key could be removed and the right magneto was not grounded. The key tumbler was removed but company personnel reportedly were unable to determine why the key could be removed from the left, right, both, and start positions. With NTSB permission, a black rubber coating was removed from the end of the key that would be held by hand during rotation of the key. The key was marked with "Y11", "USA" and a single line parallel to the long axis. It also could not be determined if the key was the original supplied with the switch as there were no markings to indicate it was an original key (manufacturer logo and key number). The manufacturer representative indicated that the drawing specifies the key to be brass, but does not specify what type of brass. The key P/N is specified to be L1054B from ILCO (Kaba Ilco Corporation). The switch was reassembled and it and the key were sent to the NTSB Materials Laboratory.

According to the NTSB Materials Laboratory factual report, examination of the cut surfaces of the key notches revealed relatively smooth and reflective surface features consistent with a worn surface on the flank of the notch adjacent to the key retention ridge. A smooth and reflective surface consistent with wear was also observed on the tip end of the shank opposite the notched side. Examination of the key cylinder revealed a quadrilateral-shaped area with a smooth and reflective surface consistent with wear on the lower side of the key slot. The location and shape of the worn area was consistent with wear contact with the tip of the key as it was inserted and removed. Although not part of the report, the key material was determined to be brass alloy c377.

MEDICAL AND PATHOLOGICAL

An autopsy examination was not requested by NTSB or FAA, nor was an autopsy or external examination performed by the medical examiner's office. Forensic toxicology was performed on specimens of the pilot by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The toxicology report stated no ethanol or tested drugs were detected. Testing for cyanide was not performed and the specimens were insufficient for carbon monoxide analysis.

TESTS AND RESEARCH

Previous NTSB Investigations

A review of the NTSB's database for previous accidents and incidents in which a loss of ignition switch-to-key integrity led to unintended engine startup revealed three previous investigations. In all three, the key was not in the ignition switch which was believed to be in the off position, but the engine started which resulted in injury or uncommanded movement of the airplane. The three cases were NTSB Case Nos. NYC82FNA13, CHI87DER02, and BFO90DIG02.

FAA Service Difficult Reports (SDR's)

A search of FAA SDR's database from 1993 to October 2018 revealed four reports which cited that the ignition key could be removed from the ignition switch in various positions. 

Pilot Information

Certificate: Private
Age: 70, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: None
Other Aircraft Rating(s): None
Restraint Used: None
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: BasicMed With Waivers/Limitations
Last FAA Medical Exam: 06/12/2017
Occupational Pilot: No
Last Flight Review or Equivalent: 07/10/2017
Flight Time:  1500 hours (Total, all aircraft), 811 hours (Total, this make and model), 1453 hours (Pilot In Command, all aircraft), 15 hours (Last 90 days, all aircraft), 12 hours (Last 30 days, all aircraft), 2 hours (Last 24 hours, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: Cessna
Registration: N1311S
Model/Series: 182 P
Aircraft Category: Airplane
Year of Manufacture: 1976
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 18264876
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection: 01/10/2018, Annual
Certified Max Gross Wt.: 2950 lbs
Time Since Last Inspection: 31 Hours
Engines: 1 Reciprocating
Airframe Total Time: 4895 Hours
Engine Manufacturer: Continental
ELT:
Engine Model/Series: O-470-S
Registered Owner: On file
Rated Power: 230 hp
Operator: On file
Operating Certificate(s) Held: None 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KRZR, 860 ft msl
Distance from Accident Site:
Observation Time: 1655 EDT
Direction from Accident Site:
Lowest Cloud Condition: Few / 6000 ft agl
Visibility: 10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: Calm /
Turbulence Type Forecast/Actual: Unknown / Unknown
Wind Direction:
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 29.98 inches Hg
Temperature/Dew Point: 31°C / 16°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Cleveland, TN (RZR)
Type of Flight Plan Filed: Unknown
Destination: Blairsville, GA (DZJ)
Type of Clearance: None
Departure Time: 1648 EDT
Type of Airspace: 

Airport Information

Airport: Cleveland Regional Jetport (RZR)
Runway Surface Type: N/A
Airport Elevation: 860 ft
Runway Surface Condition:
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: None

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: None
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude:  35.211944, -84.798056 (est)