Sunday, April 28, 2019

Loss of Control in Flight: Cessna 180, N3119D; accident occurred July 22, 2017 in Austin, 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; San Antonio, 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.govN3119D



Location: Austin, TX
Accident Number: CEN17LA283
Date & Time: 07/22/2017, 1735 CDT
Registration: N3119D
Aircraft: CESSNA 180
Aircraft Damage: Substantial
Defining Event: Loss of control in flight
Injuries: 2 Minor, 1 None
Flight Conducted Under: Part 91: General Aviation - Business - Sightseeing 

On July 22, 2017, at 1735 central daylight time, a Cessna 180, N3119D, did not attain/maintain a positive climb rate during initial climb from Lake Travis near Austin, Texas. The float-equipped airplane descended and impacted Lake Travis, nosed-over, and sank. The airplane sustained substantial damage. The commercial pilot was uninjured, and the two passengers sustained minor injuries. The airplane was operated by Up Above Austin LLC under Title 14 Code of Federal Regulations Part 91 as an air tour flight that was not operating on a flight plan. Day visual meteorological conditions prevailed at the time of the accident for the local flight that was originating at the time of the accident.

One of the passengers stated that she reserved the 30-minute air tour flight for her and her husband's anniversary. She stated that she learned of the operator from an internet search she performed and "looked at the reviews" about the operator. She said there was another air tour operator in the Austin, Texas area but that operator did not have seaplanes. She said the pilot did not provide a briefing on the use of the seatbelts or the airplane door, but he did brief them how to use the life jackets/vests. She said the pilot told them "you won't need [life vests], it goes over your shoulder and just pull on the yellow piece." She said they were wearing their life vests for the flight.

The pilot stated that he performed a preflight inspection of the airplane before the air tour flight for the two passengers with one passenger seated in the front right seat and the second passenger seated in the rear right seat. The pilot stated that he briefed them how to put the life vests on and their use outside of the airplane. He said the during the taxi out he briefed the passengers on emergency procedures (how to open doors, use the seatbelts, life vest, etc.).

The pilot said he set the wing flaps to 20 degrees for takeoff. He said the outside air temperature was 100 degrees and winds were about 10-15 knots, which favored a southeast departure. He expected an airplane performance reduction due to the outside air temperature. He said the lake condition was choppy from boats on the lake.

He said that it took "a bit longer than usual" to get on the step due to the outside air temperature and the "roughness" of the lake as the airplane bounced through the choppiness. He said the airplane hit a couple of waves just before getting to a take-off speed of about 45 mph, lifted off for a moment then settled back down, and bounced a couple of times. He said all indications appeared normal, and the airplane began to climb, but he did not feel the usual acceleration after leaving the water. The pilot said that once the airplane was flying in ground effect, he levelled the airplane a little to allow the airspeed to increase, but the airspeed did not increase. About 25-35 feet above the water, the airplane began to descend, and it could not maintain airplane altitude or airspeed. The pilot pitched the nose down a little to increase airspeed, but there was no substantial increase in airspeed, and the airplane descended faster. The pilot began looking for a landing path and saw a pontoon boat converging on the flight path from the right, so turned the airplane away from the boat to the left, and the plane quickly began to descend. The airplane struck the water with the left pontoon, which collapsed and contacted the rotating propeller. The pilot shut the engine down, and the airplane began to list to the left. The left wing tip was in the water, and the pontoon had a large hole.

The pilot stated that he instructed the passengers to exit the airplane from the right door as the left door was angled down toward the water. He helped them open the door and held it open for the front seat passenger to exit the airplane. When the front seat passenger removed her seat belt, she also took off her life vest, stood on the door frame and put her phone and belongings in her purse, and then asked an approaching boat if she could jump in. The pilot stated he asked her to put her life vest back on but he was not sure that she heard him.

A Sheriff's boat pulled up next to the airplane, asked the other boats to back away, and told the front passenger to jump towards the Sheriff's boat. She jumped towards the aft of the airplane and a Sheriff's officer jumped into the water to get her. The airplane began to roll to the left about that time, and the pilot held the right seat back forward to allow the rear seat passenger to exit the airplane.

The pilot said the he and the rear seat passenger could not simultaneously exit through the door so the pilot exited first and held the door open for the rear passenger. The airplane continued to list until it was capsized but was still floating on the pontoons. The pilot was standing on the bottom surface of the wing and jumped toward the front of the plane and then swam to the Sheriff's boat. Sheriff's personnel told the pilot to get in the boat, so he climbed up as the boat got closer. The rear seat passenger was struggling to get into the boat, so the pilot jumped back in the water and helped him get in the boat after which the pilot got back into the boat. During this time, Sheriff's personnel got the front passenger into the boat.

The front seat passenger stated that during the pilot's first takeoff attempt, it was "very bumpy, rocky, and rough," and he looked "very uneasy"; he tried to get us up, and the airplane came back down "roughly". He attempted a second takeoff, during which it was "rough and rocky". The pilot tried to get the airplane airborne again and it came down "hard". He attempted a third takeoff, and it was still "VERY bumpy and rocky"; this time the airplane lifted off from the water and attained an altitude of about 75 – 100 feet above the water. The airplane then started descending at a fast rate. The pilot never mentioned any problems until we were about to crash. The pilot said, "Oh that's not good." right before impact with the water. She said once they crashed, the pilot sat in his seat not saying anything. The front seat passenger turned around and looked at her husband to make sure he was okay and noticed that water was entering the plane on the left side. The front seat passenger then said to the pilot, "shouldn't we get out the plane," and the pilot said, "oh yea, yea we should." The front seat passenger unbuckled her seatbelt and life jacket, not realizing that she unbuckled the life jacket, and then asked, "How do I open the door? Someone help." My husband (seated in the rear seat) then reached forward and lifted the latch to open the door. The front seat passenger said she got out "in a hurry" to let the others out since her (right-hand) door was the only exit available. Once she exited the airplane, she leaned against the rear part of the plane because gravity was pushing her backward towards the sinking airplane. Boats arrived and asked if they needed help, the waves pushed the airplane further down. The Sheriff's boat arrived and told the other boats to back up so they could come in closer. The Sheriff's officer on the boat reached her hand out and the passenger reached back but she could not reach the officer since the boat was higher than the sinking airplane. The front seat passenger jumped toward the Sheriff's officer, fell into the water, and she started to drown. The front seat passenger's purse was wrapped around her arm preventing her from using her left arm, and the current was strong. The front seat passenger came to the surface of the water and yelled "HELP" and went back down. The Sheriff's officer took off her life jacket and dove in to save her. The other Sheriff's officer on the boat threw out a blue float that she grabbed onto; then she saw her husband swimming from the left side of the airplane towards her. The rear seat passenger's life vest never inflated. The front seat passenger said she never saw the pilot until a second Sheriff's boat arrived and then the pilot got into that boat.



Pilot Information

Certificate: Commercial
Age: 52, Male
Airplane Rating(s): Single-engine Land; Single-engine Sea
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 2 Without Waivers/Limitations
Last FAA Medical Exam: 11/20/2016
Occupational Pilot: Yes
Last Flight Review or Equivalent: 11/20/2016
Flight Time:  543 hours (Total, all aircraft), 139 hours (Total, this make and model), 408 hours (Pilot In Command, all aircraft), 54 hours (Last 90 days, all aircraft), 12 hours (Last 30 days, all aircraft), 0 hours (Last 24 hours, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: CESSNA
Registration: N3119D
Model/Series: 180
Aircraft Category: Airplane
Year of Manufacture: 1955
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 31917
Landing Gear Type: Float;
Seats: 4
Date/Type of Last Inspection: 09/20/2017, Annual
Certified Max Gross Wt.: 2850 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time:
Engine Manufacturer: CONT MOTOR
ELT: Installed, not activated
Engine Model/Series: O-470-J
Registered Owner: M1 Aviation LLC
Rated Power: 225 hp
Operator: Up Above Austin, LLC
Operating Certificate(s) Held: None
Operator Does Business As: Up Above Austin
Operator Designator Code: EPUJ 

The accident airplane was a 1955 Cessna 180 equipped with a Continental O-470-J1, serial number 45344-5-J, engine.

Up Above Austin LLC had a Letter of Authorization (LOA) under Part 91.147, effective December 21, 2016, that was authorized by the Federal Aviation Administration for the operator to operate three aircraft for commercial air tour operations, which were: Cessna 172RG, N9593B; Cessna 180, N3119D; Cessna 182R, N3665C. The LOA listed the pilot as responsible for business management and aircraft maintenance.

At the time of certification of the 1955 Cessna 180, the airplane was not required to be equipped with shoulder harnesses. Both front seats had shoulder harness installations. The rear seats were not equipped with shoulder harnesses. The pilot seat had components of a secondary stop installation, in which the inertia reel was installed into the airplane frame and not into the airplane structure. Cessna's Single Engine Service Bulletin SEB07-5 Revision 6, Pilot and Copilot Secondary Seat Stop Installation specifies that the inertia reel is to be secured to the airplane structure. The purpose of SEB07-5 was to assist in preventing uncommanded rearward movement of the pilot and copilot seats. The installation was designed to assist in providing an additional margin of safety by limiting the aft travel of the seat should the primary seat latch pin(s) not be properly engaged in the seat rail/track. In certain instances, seat slippage could result in some pilots not being able to reach all the controls and/or subsequently losing control of the airplane.

The FAA inspector stated the airplane records did not have a weight and balance form. A review of the airplane logbook revealed a maintenance entry by the pilot, dated April 5, 2017, listed the airplane empty weight as 2,221 lbs. and a center of gravity of 38.13 inches. The FAA inspector requested, and the pilot provided weight and balance calculations of the accident flight following the accident using a cell phone app. The pilot stated that there was approximately 18 gallons of fuel aboard. He said that he asked the passengers their weights, which they said were 140 lbs. and 200 lbs. The pilot used 180 lbs. for his weight his weight and balance calculations showed that empty weight was 2,221 lbs., the takeoff weight was 2,849 lbs., and the gross weight was 2,850 lbs.

The front seat passenger stated that the pilot never asked for their weights. The passenger stated she weighed 150 lbs., and her husband weighed 200-205 lbs.

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: AUS, 542 ft msl
Distance from Accident Site:
Observation Time: 1653 CDT
Direction from Accident Site:
Lowest Cloud Condition: Scattered / 7500 ft agl
Visibility:  10 Miles
Lowest Ceiling: Broken / 25000 ft agl
Visibility (RVR):
Wind Speed/Gusts: 5 knots /
Turbulence Type Forecast/Actual: / None
Wind Direction: 170°
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 29.86 inches Hg
Temperature/Dew Point: 37°C / 18°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Austin, TX
Type of Flight Plan Filed: None
Destination: Austin, TX
Type of Clearance: None
Departure Time: 1735 CDT
Type of Airspace:

Airport Information

Airport: Lake Travis (N/A)
Runway Surface Type: Water
Airport Elevation: 681 ft
Runway Surface Condition: Water--choppy
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: None

Wreckage and Impact Information

Crew Injuries: 1 None
Aircraft Damage: Substantial
Passenger Injuries: 2 Minor
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Minor, 1 None
Latitude, Longitude: 30.420556, -97.910278 (est)

Post-accident examination of the airplane confirmed flight control continuity from the control surfaces to the cockpit controls. The float gear handle was in the water position. The water rudders were in the up position. The tachometer indicated 21,940 hours.

Examination of the pilot's seat revealed it was latched, secure, and in place. Cockpit throttle, mixture, and propeller control continuity was confirmed. Both propeller blades had chordwise gouging and leading edge semi-circular deformations consistent with rotational impact. The engine air intake was unobstructed. Borescope examination of the cylinders showed evidence of corrosion consistent with water immersion. The top spark plugs exhibited similar corrosion features and did not display carbon fouling. Hand rotation of the propeller confirmed drive and valve train continuity to the rear accessory case, and thumb compression through the top spark plug holes was confirmed during rotation. During the propeller rotation, the left magneto produced a sound consistent with a repetitive actuation of its impulse coupling, and no spark was produced through the ignition harness, which was secured to magneto terminal leads. The magnetos were removed and did not spark when the magnetos were rotated by hand. Both magnetos had internal corrosion consistent with water immersion. After both magnetos' contact points were cleaned, the magnetos were bench tested and produced a spark in correct firing order across a 4 mm air gap. The inlet line to the carburetor contained water, and the carburetor screen did not contain debris.

A J.P. Instruments EDM-700 and a J.P. Instruments FS-450 cockpit display were removed and sent to the National Transportation Safety Board (NTSB) Vehicle Recorder Division for download of nonvolatile memory.

Flight Recorders

The NTSB Vehicle Recorder Division's download of accident flight data of the FS-450 display showed 0.2 gal of fuel remaining and 54.8 gal of fuel used. The display relied on the pilot to reset the fuel capacity when refueling the aircraft, then the device uses fuel-flow instrument data to calculate the used and remaining fuel in the aircraft's fuel tank.

The JPI EDM-700 download showed that the cylinder head temperatures of the six engine cylinders had increased from about 200 degrees Fahrenheit (F) to 380-450 degrees F with a corresponding increase in exhaust gas temperatures of 1,300 – 1,500 degrees F.

The passenger(s) provided a video they had taken of the accident flight. That video was summarized by the NTSB Vehicle Recorder Division and is available in the docket for this report.

Additional Information

The Airplane Flying Handbook (FAA-H-8083-3B), Chapter 5, Ground Effect on Takeoff, stated, in part:

"Due to the reduced drag in ground effect, the airplane may seem to be able to take off below the recommended airspeed. However, as the airplane climbs out of ground effect below the recommended climb speed, initial climb performance will be much less than at [best rate of climb speed] or even [best angle speed]. Under conditions of high-density altitude, high temperature, and/or maximum gross weight, the airplane may be able to lift off but will be unable to climb out of ground effect. Consequently, the airplane may not be able to clear obstructions. Lift off before attaining recommended flight airspeed incurs more drag, which requires more power to overcome. Since the initial takeoff and climb is based on maximum power, reducing drag is the only option. To reduce drag, pitch must be reduced which means losing altitude. Pilots must remember that many airplanes cannot safely takeoff at maximum gross weight at certain altitudes and temperatures, due to lack of performance. Therefore, under marginal conditions, it is important that the airplane takes off at the speed recommended for adequate initial climb performance."

2 comments:

Anonymous said...

Well after reading the investigation report it’s clear that the passengers are going to be filing a lawsuit. The writing is on the wall. They should be grateful they’re alive. Everyone is looking for some type of free compensation lawyers

Anonymous said...

By the report, looks like the plane was not fit for flight! Corroded cylinders, bad mag(s), etc. low time Pilot choked when he should have acted. lots of conflicting stories here