Saturday, April 20, 2019

The Wolk Law Firm (also known as “Arthur Alan Wolk Associates”) sues National Transportation Safety Board, says withholding of crash investigation records constitutes Freedom of Information Act (FOIA) violations


PHILADELPHIA, Pennsylvania – A Philadelphia law firm has sued the National Transportation Safety Board (NTSB) and alleged the government organization has illegally withheld information and evidence from families and loved ones of multiple crash accident victims, in violation of the Freedom of Information Act.

The Wolk Law Firm (a.k.a. “Arthur Alan Wolk Associates”) of Philadelphia filed suit in the U.S. District Court for the Eastern District of Pennsylvania on April 2nd, 2019 versus the United States of America/NTSB of Washington, D.C.

The plaintiff firm is “routinely retained to investigate aircraft accident investigations, and to pursue legal remedies for its clients.”

The lawsuit refers to the NTSB investigations surrounding several matters, including those for the following estates and individuals: Berke Morgan Bates and Henry John Cullen III; Christopher Freeman Byrd, Phillip Armstrong Byrd and Grady G. Byrd III; Lauren Johnson Chase; Arrin Farrar; Troy L. Gentry; William Gordon; Robert and Brenda Hinkle; John Michael and Dawn Skinner; Ryan Lee McCall; Gerald and Diane Stubbs; Gregory Torres; Diana Soto, Evelyn Walker and James Walker.

“The NTSB is charged with the investigation of civil aviation accidents. The NTSB, according to its own regulation, takes custody of aircraft wreckage and other evidence, including photographic evidence, videos, notes, witness statements and other information after an accident. The NTSB is charged to perform any inspection, examination or test promptly, and to make the results available,” per the lawsuit.

However, the suit alleges the NTSB instead relies upon manufacturers of civil aircraft and aircraft components to provide technical expertise and help it complete crash investigations – but furthermore, that this relationship has created a situation where these same manufacturers received unfettered access to and editorial control over crash investigation materials and evidence, the very same access which has been denied to victims of aviation crashes, their loved ones and representative agents. The suit says this constitutes a violation of the Freedom of Information Act.

“The NTSB has withheld critical information, including accident wreckage, videos of the flight, flight performance data, photographs of the investigation, correspondence with the manufacturers and other documents which available to the manufacturers, but not to the victims up to, or even past the statute of limitations,” the lawsuit says.

“Plaintiff brings this actions on behalf of accident victims and their families, who have been prevented access to wreckage, critical documents, data and evidence of plane crashes that have resulted in severe injury or death, and the NTSB has continually denied access to any remedy.”

Counsel for the plaintiff did not respond to a request for comment from the Pennsylvania Record.

In a separate lawsuit, last week U.S. District Court Judge Eduardo C. Robreno found that Freedom of Information Act exemptions apply to the NTSB’s refusal to provide document and video evidence in a crash investigation involving Don and Ingrid Goldstein.

However, Robreno also found the NTSB provided “no justification to withhold information regarding the Goldstein aircraft wreckage, or the wreckage itself if the NTSB still has it," thereby granting the NTSB’s motion for summary judgment as to the aforementioned documents and videos, but also ordering the NTSB to “produce chain-of-custody information about the wreckage or make the wreckage available for inspection.”

For counts of obstruction of justice and violation of due process, violation of 14 C.F.R. Section 837.4 and violation of the Freedom of Information Act, the plaintiff is seeking an order compelling the NTSB to release any and all documents, data and evidence that relates to the crash complained of herein, and such other and further relief as the Court may deem just and proper.

The plaintiff is represented by Cynthia Marie Devers of The Wolk Law Firm, in Philadelphia.

U.S. District Court for the Eastern District of Pennsylvania case 2:19-cv-01401

Original article can be found here ➤ https://pennrecord.com


Cirrus SR22T, N227RR: Accident occurred November 28, 2014 near Hampton-Varnville Airport (3J0), Hampton, South Carolina 

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

Additional Participating Entities: 
Federal Aviation Administration / Flight Standards District Office; West Columbia, South Carolina
Continental Motors Inc; Mobile, Alabama 
Cirrus Design Corporation; Duluth, Minnesota 

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

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

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

Location: Hampton, SC
Accident Number: ERA15LA062
Date & Time: 11/28/2014, 1158 EST
Registration: N227RR
Aircraft: CIRRUS DESIGN CORP. SR22T
Aircraft Damage: Substantial
Defining Event: Loss of engine power (total)
Injuries: 1 Serious, 3 Minor
Flight Conducted Under: Part 91: General Aviation - Personal

Analysis

The private pilot was conducting a personal cross-country flight with three passengers on board. The pilot reported that, during the preflight inspection, he checked the quantity of engine oil and verified that there was an adequate supply of engine oil on board. During cruise flight, about 9,000 ft mean sea level (msl), the oil pressure indication decreased to 0, which resulted in both audible and visual warnings. The engine power then reduced to idle, and the pilot’s attempts to restore engine power by moving the throttle were not successful. The pilot subsequently diverted to a nearby airport about 7.5 nautical miles (nm) away. He stated that he descended the airplane slightly faster than the published best glide airspeed. When the airplane was at 800 ft msl and he realized it would not be able to land at the intended runway, he deployed the ballistic parachute. The airplane descended under the canopy, hit trees, descended to the ground, and then came to rest about 3/4 nm from the approach end of the intended runway. 

A postaccident examination and test run of the engine revealed no evidence of preimpact mechanical failures or malfunctions. Further, normal engine oil pressure was noted during the engine run; however, subsequent examination of the oil pressure transducer revealed that it was faulty and would have resulted in an erroneous oil pressure indication, as reported by the pilot. Further, although the pilot indicated that the engine lost power following the loss of oil pressure indication, which was supported by data downloaded from the onboard recording devices that showed decreased readings for fuel flow, exhaust gas temperature, and cylinder head temperature, the loss of engine power was consistent with the pilot’s operation of the engine controls not with a mechanical malfunction or failure of the engine. 

Although the pilot reported that he descended the airplane slightly above the published best glide speed after first locating the alternate airport, the recorded data indicated that he descended at an indicated airspeed far greater than the published best glide speed for the majority of the descent. If the pilot had slowed to and maintained the published best glide speed either at the time of the first abnormal indication or after first locating the alternate airport, it is likely that the airplane would have been able to reach the intended runway and land successfully. 

Further, although the pilot reported that he deployed the parachute at 800 ft msl, it was actually deployed when the airplane was at 453 ft msl, or about 340 ft above ground level (agl), excluding the treetop heights. Although the successful deployment of the parachute has been demonstrated at less than 400 ft agl, the low-altitude deployment likely contributed to the severity of the accident by not allowing the parachute to fully deploy and adequately decelerate the airplane into an approximately level attitude. 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot’s improper decision to descend the airplane at an airspeed greater than the published best glide speed following an erroneous oil pressure indication, which resulted in an off-airport landing. Contributing to the erroneous oil pressure indication was the faulty oil pressure transducer. Contributing to the severity of the accident was the pilot’s late deployment of the ballistic parachute system.

Findings

Aircraft
Pressure - Malfunction (Factor)

Personnel issues
Decision making/judgment - Pilot (Cause)
Use of equip/system - Pilot (Cause)
Delayed action - Pilot (Factor)



Factual Information

On November 28, 2014, about 1158 eastern standard time, a Cirrus Design Corporation SR22T, N227RR, descended under the canopy of the Cirrus Airframe Parachute System (CAPS) and landed into a wooded area near Hampton-Varnville Airport (3J0), Hampton, South Carolina. The private pilot and two passengers sustained minor injuries, while one passenger sustained serious injuries. The airplane was substantially damaged. The airplane was registered to and operated by Header Bug LLC, under the provisions of 14 Code of Federal Regulations (CFR) Part 91 as a personal flight. Visual meteorological conditions prevailed at the time and an instrument flight rules flight plan was filed. The flight originated from Sarasota/Bradenton International Airport (SRQ), Sarasota, Florida, about 0933, and was destined for Orangeburg Municipal Airport (OGB), Orangeburg, South Carolina.

The pilot stated that after arrival at SRQ, the airplane was removed from the hangar and, as part of his preflight inspection, he checked the quantity of engine oil, which was indicating 8 quarts, or full. After engine start, he taxied to the run-up area, and while there performed an engine run-up using the checklist. It included a check of the magnetos at 1,700 rpm, and a check of the load on the alternators. When the checklist was completed he obtained his IFR clearance, and departed from runway 04.

After takeoff the flight proceeded towards the destination airport while remaining in contact with air traffic control. About 3 minutes after last checking the engine parameters, noting all engine parameters (specifically, oil temperature, oil pressure, and CHT) were in the green, or at 1153:02, the oil pressure indication first began to decrease from the steady state reading. The oil pressure decreased to zero over the next 2 seconds and was annunciated by an audible warning. The airplane at that time was at 9,000 feet mean sea level (msl), or 8,542 feet pressure altitude and was about 9.5 nautical miles and 168 degrees from 3J0. The pilot reported the engine power went to idle, and he did not hear any sounds from the engine, which was running smooth but was idled back. He reported he had no control over the power, and did not observe any oil or mist coming out of the engine and did not notice any smoke from the engine from oil getting onto a hot exhaust. He also reported he did not hear a change in sound from the propeller as if the propeller had changed pitch, and the propeller never stopped. The passenger in the right front seat read the display on the multi-function display (MFD) that the oil pressure displayed in the red showing 0 oil pressure. In addition, on the primary flight display (PFD) a red highlighted "WARNING" about the oil pressure displayed. He fully enrichened the mixture control and moved the throttle in an attempt to restore engine power but there was no response.

Using the on-board avionics he confirmed the nearest airport was 3J0, and declared an emergency with air traffic control, advising the controller at 1153:39, "…I got an oil pressure going haywire." The controller advised the pilot that 3J0 was the nearest airport and was located 7.9 miles from the aircraft's present position. The pilot informed the controller at 1154:09 that the airport was in sight; the airplane at that time was at 7,647 feet msl and was located about 7.5 nautical miles and 163 degrees from the approach end of runway 29 at 3J0. The controller then asked the pilot if he needed assistance on the ground at 3J0, and he indicated he did. The controller subsequently informed the pilot that emergency crews were on their way to 3J0.

The pilot reported that with the engine at idle, he descended at 98 knots, although the best glide speed was reported to be 88 knots. After realizing he was unable to land at 3J0, he informed the passengers to tighten their restraints (seatbelts and shoulder harnesses) before activating the CAPS. At 1157:36, the pilot informed the controller that he was "…inches from making this uh runway before I have to deploy this chute on here so." He indicated that he pulled the CAPS activation handle at 800 feet but could not recall the airspeed at chute pull. While under the canopy, the tail came down just as the airplane hit the trees. He attributed this to the altitude of deployment. A portion of a wing was knocked off and the tail was almost separated. The airplane descended to the ground, and he reported the contact was hard. He later indicated securing the fuel selector while on the ground.

The airplane came to rest in a wooded area about ¾ nautical mile and 110 degrees from the approach end of runway 29 at 3J0.

According to the individual involved with the recovery of the airplane, there were no obvious discrepancies noted with the engine, and no oil was observed inside the engine compartment. In the resting position of the airplane (slight nose low), a total of four quarts registered on the oil dipstick (actually called an oil gage rod and cap assembly, part number (P/N 656616-2); which was tightly secured. After the airplane was raised from the ground to a level attitude, no oil streaking or stains were noted on the bottom of the fuselage or airframe. In that position, the oil quantity registered slightly above the "8" mark on the oil gage rod cap assembly, which was full. A copy of the NTSB Record of Conversation with the individual is contained in the NTSB public docket.

Following recovery of the wreckage, an examination of it and the engine was performed by representatives of the airframe and engine manufacturer with NTSB oversight. The avionics that recorded and retained data were downloaded with NTSB permission by a representative of the airframe manufacturer. The downloaded data was then provided to the NTSB Vehicle Recorder Division. Examination the engine revealed the oil quantity was approximately 8 quarts and the oil was "like new." At the request of the NTSB investigator-in-charge, the oil pump cover was removed to inspect the oil pump; no discrepancies were noted. Crankshaft, camshaft, and valve train continuity was confirmed. Examination of the wiring associated with the oil pressure transducer revealed the connection at the transducer was properly connected and strain relief of the wire harness at the transducer was noted. Electrical continuity was confirmed from the plug at the transducer for the supply and output pins to the appropriate pins at the firewall connection; however, continuity was not confirmed for the ground pin at the transducer connector. No damage to the wiring harness was reported and the condition of each connector and pins were satisfactory. A portion of the wiring harness was removed for further examination of the ground connection related to the oil pressure transducer.

Examination of the throttle and mixture controls in the cockpit revealed the throttle was full forward and the mixture control was in a mid-range position between full rich and idle cut-off, which matched the positions at each respective control in the engine compartment. Examination of the engine controls in the engine compartment revealed they were properly secured and once documented, full, unrestricted stop-to-stop movement was observed by activation of the cockpit controls. Examination of the engine-driven fuel pump revealed the drive coupling was intact and fuel was noted in the flexible hose from the outlet of the pump to the fuel metering unit. No fuel was noted at the inlet to the fuel pump. Examination of the CAPS revealed the rear harness remained snubbed. The fuel selector was found in the off position. The engine was removed from the airplane for an attempted engine run at the manufacturer's facility. Additional items retained by NTSB included the oil pressure transducer, the Cirrus Recoverable Data Module (RDM), and the SanDisk 4GB SDHC Card from the Garmin G1000. Additional details concerning the airframe and engine examination results are contained in NTSB field notes or report from the engine manufacturer representative that are contained in the NTSB public docket.

At the engine manufacturer's facility, while in the presence of NTSB personnel, the engine was removed from the crate and impact damaged components were replaced. Additionally, the oil pump cover which had been previously removed was reinstalled with new silk thread. The engine was mounted in a test stand with a test club propeller installed and included the engine oil cooler, but did not include the accident oil pressure transducer. A flexible fluid carrying hose was attached to the outlet of the oil cooler (same location at the oil pressure transducer location) and connected directly to the test bench analog oil pressure gauge. During the initial run, an oil leak was noted at the oil pump. The engine was secured and the silk thread at the oil pump cover was repositioned. The oil pump cover was re-installed and the engine was started and found to operate normally. During the second engine run normal oil pressure and engine operation was noted. Examination of the retained electrical wiring associated with the oil pressure transducer revealed continuity of the ground from the plug at the oil pressure transducer to the bundled location also shared by the tachometer sensor, fuel flow sensor, and manifold pressure sensor. A copy of the NTSB report and report from the engine manufacturer's representative concerning the engine run and wiring harness examination are contained in the NTSB public docket.

Following the engine run, the oil pressure transducer was examined at the manufacturer's facility with FAA oversight. The transducer was marked in part with "12-635-004" which is the Cirrus part number (P/N), and "G1014" which indicates it was manufactured July 10, 2014. The examination began with a visual examination which confirmed the transducer did not appear damaged. The pressure port was not obstructed or damaged, and there was no damage on the connector and no signs of fretting on the pins. The transducer was then subjected to x-ray examination which revealed there was no evidence of a loose contact or damage inside the sensor. The transducer was then subjected to bench testing which involved applying up to 5 volts DC power and 150 PSIG. The transducer worked with no discrepancies and was subjected to a tap by a mallet which did not change the output voltage. The transducer was then subjected to a parametric test at specific pressures from 0-150 PSID and at specified test temperatures between -30.0 degrees Celsius to +100.0 degrees Celsius. The unit passed testing at all test temperatures and pressures up to testing at +100.0 degrees Celsius and 100 PSID, but failed the remainder of the pressure testing at that temperature. A copy of the report from the transducer manufacturer is contained in the NTSB public docket.

The specification for the oil pressure transducer identified as Cirrus Part Number (P/N) 12-635-004, indicated the input pressure range was 0 to 150 PSIG, and the operating temperature range was -30 degrees to +100 degrees Celsius. The expected vibration was 10 to 2000 Hz, and the expected operating life was 10 million full pressure cycles minimum.

A review of the maintenance records revealed the airplane was manufactured in September, 2014. Since manufacture, there was no record of any work performed to the oil pressure transducer or any reported discrepancy (excluding the accident flight) with the oil pressure indication. The engine oil and filter were noted to have been changed twice. The first occurred on November 14, 2014, at tachometer time of 31.40, and the second occurred on November 20, 2014, at tachometer time of 44.10. The airplane hour meter and flight meter were reported to be 62.7 and 51.7 hours, respectively. Excerpts of the maintenance entries are contained in the NTSB public docket.

According to the Maximum Glide Chart found in the Pilot's Operating Handbook and FAA Approved Airplane Flight Manual (POH/AFM), the best glide speed at gross weight is published to be 92 KIAS, resulting in a glide ratio of 8.6:1. Based on the location and altitude being flown when the pilot reported 3J0 was in sight (7,647feet msl), and subtracting the airport field elevation (113 feet), flying at the published best glide speed would have allowed a glide distance of approximately 10.6 nautical miles. The calculations did not take into account the affect of wind. Further review of the emergency procedures section of the POH/AFM revealed that it contained a section related to oil pressure warning and revealed the checklist items indicated that if the oil pressure was low to reduce power to minimum required for sustained flight and land as soon as possible. The amplification section of that checklist indicated that low oil pressure may be caused by a loss of a significant amount of its oil and engine failure may be imminent. The emergency procedures section for "Engine Failure In Flight" of the POH/AFM indicated to establish best glide speed, and then to trouble shoot to restore engine power.

Further review of the POH/AFM pertaining to the deployment characteristics of the CAPS indicated that about 8 seconds after deployment, the rear riser stub line would be cut and the airplane tail would drop down into its final approximately level attitude. The descent rate was expected to be less than 1,700 feet-per-minute with a lateral speed equal to the velocity of the surface winds. Chapter 10 of the POH/AFM related to the CAPS indicated that although no minimum altitude for deployment had been set, "A low altitude deployment increases the risk of injury or death and should avoided. If circumstances permit, it is advisable to activate the CAPS at or above 2,000 feet AGL." The POH/AFM also indicated that as a data point, altitude loss from level flight deployments had been demonstrated at less than 400 feet. Eight seconds after deployment, the rear riser snub line would be cut and the airplane tail would drop down into its final approximately level attitude. The ground impact was expected to be the equivalent to touchdown from a height of approximately 13 feet. Excerpts from the POH/AFM are contained in the NTSB public docket.

According to the NTSB Recorded Flight Data Specialist's Factual Report concerning the Recoverable Data Module (RDM), downloaded data recorded in 1 Hz increments began at 0931:00, and ended at 1158:20, which contained the takeoff to about 8 seconds after deployment of the CAPS. Further review of the downloaded data revealed normal engine indications were noted from acceleration for takeoff at 0933:01 until about 1153:01, at which time the oil pressure was recorded to be 57 PSI. One second later, or at 1153:02, the oil pressure was recorded to be 38 PSI, while at the same time the recorded readings for rpm, fuel flow and manifold pressure, which share the same ground connection as the oil pressure ground, remained about the same as the recorded values 1 second earlier. The oil pressure indication decreased to 0 at 1153:04, and remained at that value for the remainder of the recorded data. The data for rpm, fuel flow and manifold pressure at 1153:04, remained at or near the previous recorded values. For about 34 seconds after the oil pressure indication was first recorded to be zero, the pressure altitude remained nearly the same while the indicated airspeed decreased from 143 knots to 109 knots. During the same time frame, the manifold pressure and fuel flow readings decreased, but the engine rpm remained about the same value. Beginning about 1153:38, or about 34 seconds after the oil pressure indication was noted to be 0, the pressure altitude began to decrease with a corresponding increase in airspeed which attained the highest value of 148 knots about 2 minutes later; the airspeed remained above 140 knots until 1156:09. At this time the airspeed began to decrease with a continual decrease in pressure altitude. At 1158:00, or about 5 minutes since the oil pressure began to decrease, and about 13 seconds before the CAPS was deployed, the airspeed was first noted to be less than the published best glide speed value of 92 knots. The CAPS activation handle was noted to be pulled at 1158:13,

while the airplane was at 453 feet msl and 87 knots, or approximately 340 feet above ground level. A total of 7 seconds elapsed time between the CAPS deployment and the end of recorded data was noted; the last recorded airspeed and ground speed values were 42 and 29 knots, respectively. Closer review of the recorded data from the time when the oil pressure indication was noted to be 0 revealed the engine rpm was noted to remain nearly the same for the next 4 minutes 6 seconds, while the fuel flow and manifold pressure indications were noted to begin to decrease about 2 and 3 seconds after the no oil pressure indication, respectively, and continued to decrease. Thereafter, the exhaust gas temperature and cylinder head temperatures began to decrease. A copy of the NTSB Recorded Flight Data Report and downloaded data are contained in the NTSB public docket.

A search of the Federal Aviation Administration (FAA) Service Difficulty Report (SDR) data was performed using the base Cirrus part number for the transducer. The data indicated there were a total of 8 reports; none of which were the specific complete part number of the pressure transducer in the accident airplane model. Closer review of the 8 reports indicated a total of the 6 reports were specified to be the transducer for oil pressure. Of the 6 reports, only one indicated the oil pressure went to 0. In that instance, the report indicated the oil pressure transducer was found to be inoperative. A copy of the SDR is contained in the NTSB public docket.

Cirrus personnel reported that beginning in 2010, they noticed an increase in warranty claims and customer satisfaction survey results showed a high replacement rate for oil and manifold pressure transducers which are similar and used on SR20, SR22, SR22TN, and model SR22T aircraft. The identified issue was erratic indication, which was attributed to be associated with connectors (baffler connector and connector at the transducer). Subsequently in August 2012, Service Bulletin (SB) 2X-77-04 was introduced which specified replacement in part of the oil pressure transducer and installed strain relief at the connector of the oil pressure transducer, and also removed the baffler connector. The actions of the SB were incorporated into production aircraft including the accident airplane. Cirrus personnel reported that after issuance of the SB, the number of warranty claims decreased in 2013, but increased again in 2014 and 2015. Cirrus is currently investigating and evaluating possible product improvements.



History of Flight

Enroute-cruise
Miscellaneous/other
Loss of engine power (total) (Defining event)

Emergency descent
Miscellaneous/other

Landing-flare/touchdown
Hard landing

Pilot Information

Certificate: Private
Age: 71
Airplane Rating(s): Single-engine Land
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 3 With Waivers/Limitations
Last FAA Medical Exam: 03/17/2014
Occupational Pilot: No
Last Flight Review or Equivalent: 10/20/2014
Flight Time:  300 hours (Total, all aircraft), 250 hours (Total, this make and model) 

Aircraft and Owner/Operator Information

Aircraft Make: CIRRUS DESIGN CORP.
Registration: N227RR
Model/Series: SR22T
Aircraft Category: Airplane
Year of Manufacture:
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 0884
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection:
Certified Max Gross Wt.: 3600 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 62.7 Hours at time of accident
Engine Manufacturer: Teledyne Continental
ELT:  C126 installed, activated, did not aid in locating accident
Engine Model/Series: TSIO-550-K
Registered Owner: Header Bug LLC
Rated Power: 315 hp
Operator: Header Bug LLC
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: BNL, 246 ft msl
Distance from Accident Site: 29 Nautical Miles
Observation Time: 1155 EST
Direction from Accident Site: 326°
Lowest Cloud Condition: Clear
Visibility:  
Lowest Ceiling: None
Visibility (RVR): 
Wind Speed/Gusts: 7 knots /
Turbulence Type Forecast/Actual: / Unknown
Wind Direction: 30°
Turbulence Severity Forecast/Actual: / Unknown
Altimeter Setting: 30.4 inches Hg
Temperature/Dew Point: 7°C / 3°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Sarasota, FL (SRQ)
Type of Flight Plan Filed: IFR
Destination: Orangeburg, SC (OGB)
Type of Clearance: IFR
Departure Time: 0933 EST
Type of Airspace:

Airport Information

Airport: Hampton-Varnville (3J0)
Runway Surface Type: Asphalt
Airport Elevation: 113 ft
Runway Surface Condition:
Runway Used: 29
IFR Approach: None
Runway Length/Width: 3580 ft / 60 ft
VFR Approach/Landing: Forced Landing 

Wreckage and Impact Information

Crew Injuries: 1 Minor
Aircraft Damage: Substantial
Passenger Injuries: 1 Serious, 2 Minor
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Serious, 3 Minor
Latitude, Longitude: 32.860556, -81.061667

Bell 407, N31VA: Fatal accident occurred August 12, 2017 in Albemarle County, Virginia 


Trooper Pilot Berke Bates

Lieutenant Pilot Jay Cullen


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

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Washington, DC
Transportation Safety Board of Canada
Bell Helicopter; Fort Worth, Texas
Rolls Royce Corporation; Indianapolis, Indiana 
Virginia State Police; Richmond, Virginia 

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

Commonwealth of Virginia
Department of State Police
http://registry.faa.gov/N31VA



Location: Charlottesville, VA
Accident Number: ERA17FA274
Date & Time: 08/12/2017, 1649 EDT
Registration: N31VA
Aircraft: BELL 407
Injuries: 2 Fatal
Flight Conducted Under: Public Aircraft

On August 12, 2017, about 1649 eastern daylight time, a Bell 407, N31VA, operated by the Virginia State Police (VSP), was destroyed after impacting trees and terrain in Charlottesville, Virginia. The airline transport rated pilot, and private pilot-rated observer, were fatally injured. Visual meteorological conditions prevailed, and no flight plan was filed for the public use aerial observation flight that departed Charlottesville-Albemarle Airport (CHO), Charlottesville, Virginia about 1554.

According to the VSP, the mission of the helicopter flight crew was to provide continuous video downlink to the VSP command center of the public demonstrations that were occurring in Charlottesville, Virginia. After being refueled, the helicopter departed CHO about 1554, with the airline transport pilot flying the helicopter, and observer operating the helicopter's camera.

The helicopter arrived over the city of Charlottesville at 1604, and remained over the city until 1642 when they were re-tasked to provide over-watch for the Governor of Virginia's motorcade. At 1643, the helicopter crew advised the VSP command center that they were heading directly to the motorcade, and were about 30 seconds away. About 1649, another helicopter advised the VSP command center that the accident helicopter had crashed.

Preliminary radar data provided by the Federal Aviation Administration (FAA), indicated that just prior to the accident, at 1648, the helicopter was flying at an altitude of approximately 2,200 ft above mean sea level (msl) in the area of the motorcade. At that time, the helicopter was traveling north-northwestbound before it began to turn to the right and descend rapidly. At 1648:30, radar indicated that the helicopter was descending through 1,450 ft msl, at a calculated groundspeed of 30 knots. Moments later, the helicopter descended below the floor of radar coverage, and radar contact was lost.

Approximately 37 witnesses were interviewed, and their descriptions of the altitude, direction of flight, and velocity of the helicopter varied; however, the preponderance of witness statements reported that the helicopter initially was hovering, began a rolling oscillation, began to spin (rotate about the vertical axis), and then descended in a 45° nose down attitude, while continuing to spin until it was lost from sight below the tops of the surrounding trees. They then observed a plume of smoke rising from the area of the accident site.

Preliminary review of security camera video provided by the University of Virginia corroborated statements from witnesses regarding the rotation (spinning) of the helicopter during the descent, and the nose down pitch attitude.

Examination of the accident site revealed, that the main wreckage had come to rest upright, on a magnetic heading of 333° in heavily wooded terrain, adjacent to a residence. The helicopter fuselage was highly fragmented from impact and postimpact fire damage, but most major components were present. A debris field, that was several hundred feet long was observed to the west of the main wreckage, with several pieces of debris coming to rest on the roof of the residence.

The debris field was comprised primarily of sheet metal from the tailboom, aluminum honeycomb sandwich structure from the airframe, tail rotor drive system pieces, and tail rotor control tube pieces. The main wreckage was comprised of the cockpit and cabin, baggage area, and the forward tailboom attachment to the main fuselage.

Examination of the high skid type landing gear revealed that the left landing gear skid tube was fragmented about 27 inches from the aft end of the tube. The aft cross-member had remained attached to the left landing gear skid. The left landing gear skid was also fractured from the forward cross-member above the tube cuff. The right landing gear skid was fractured from the forward and aft cross-members above the cross-member tube cuff. The right high step, which spanned the length of the right landing gear skid tube, was found loose in the wreckage, and was fractured at its forward and aft cross-member attachment points. The aft left step and the forward left step, located on the cross-member attachments, exhibited a fractured aft left step that was not recovered and an intact forward left step. The left side of the cross-members, which were normally attached to the left landing gear skid tube and curved, had a more flattened appearance than the right cross-members.

Examination of the tailboom revealed that the mid-section, which included the horizontal stabilizer, had come to rest adjacent to the forward right side of the nose section. The left horizontal stabilizer exhibited an angled cut consistent with main rotor blade contact. The outboard forward slat was separated from the left horizontal stabilizer, and the upper and lower vertical fin were separated from the stabilizer and found loose in the debris field. The right vertical fin exhibited partial fractures at the upper and lower fin but, the right horizontal stabilizer had remained intact.

The tailboom aft section, which contained the tail rotor gearbox and tail rotor, was fractured about 48.5 inches from the tail rotor axis of rotation. The tailboom aft section came to rest in a tree about 40 ft above the ground and 100-150 ft south-southwest of the main wreckage. The left side of the tailboom aft section had an impact mark consistent with contact with a tail rotor blade. The impact mark was located about 27-31 inches from the tail rotor axis of rotation.

Examination of the main rotor revealed that, all four main rotor blades (blue, orange, red, and green) were present. The inboard ends of all four were thermally damaged from the postcrash fire, and each displayed differing degrees of damage:

The whole span of the blue main rotor blade was found at the main wreckage site. An outboard section (near the tip) was fractured but was still attached to the blade, and the blade displayed evidence of low rotational energy at impact. The inboard end was thermally damaged. The blade was still attached to grip/spindle, which was still attached to the hub. The pitch horn was still attached to grip, and the pitch control link (PCL) upper rod end was attached but, the pitch link body was fractured and thermally damaged.

The blade span of the orange main rotor blade, which was primarily composed of the spar was found at the main wreckage site. Most of the afterbody was missing from this segment of blade. The spar was fractured near the outboard end, and a portion of the tip end about 24 inches-long was found in the debris field. The blade was separated from the grip/spindle, and came to rest next to the hub, which still contained the grip/spindle (but was loose from the head). The grip/spindle was fractured and exhibited evidence of thermal damage. The pitch horn and PCL upper rod end was still attached to the grip. The PCL body was fractured and thermally damaged.

An inboard section of the red main rotor blade remained attached to the grip/spindle. The blade was fractured about 66 inches from the blade retaining bolts, though a portion of the spar remained, measuring about 78 inches in length. This remaining portion of spar was missing its afterbody and the leading-edge abrasion strip, the latter of which was found loose in the wreckage. A 103-inch-long piece of the blade was found under large branches about 20 ft south-southwest of the main wreckage. The blade piece displayed an impact mark on the leading edge, around the 128-inch blade station position. The blade remained attached to the grip/spindle and the pitch horn remained attached, but the pitch horn lug normally connected to the PCL upper rod end was fractured with signatures consistent with overload. The PCL upper rod end and its attached pitch horn lug were not recovered. A tip end from the blade, about 16 inches in length, was found in the debris field. A separated outboard adjustable weight package was also found in the debris field.

The whole blade span of the green main rotor blade was found at the wreckage site. The tip remained attached to the blade but the lower skin was peeled/separated (but still attached). The blade remained attached to the grip/spindle and the pitch horn remained attached to the grip/spindle. The PCL was still attached to the pitch horn but the link body was fractured and thermally damaged.

The composite main rotor hub was thermally damaged and exhibited splaying. The hub connection for the red main rotor blade was fractured in the blade-chordwise direction. The main rotor head fairing also had remained installed. Removal of the fairing revealed that the eight vibration attenuation springs were in their normally installed position.

The main rotor head remained connected to the main rotor mast. The main gearbox housing exhibited evidence of sooting and thermal distress from the postcrash fire. The kaflex coupling on the forward end of the input driveshaft was intact. The aft kaflex coupling was fractured. A portion of it was found loose in the main wreckage and exhibited thermal damage. Rotation of the input driveshaft resulted in rotation of the main rotor head, consistent with drive continuity through the main gearbox. The main gearbox remained attached to the helicopter airframe and exhibited no evidence of separation.

Examination of the tail rotor drive shafts (TRDS) revealed that, the oil cooler remained installed to the airframe. The forward and aft splines were thermally damaged but did not exhibit evidence of smeared or missing spline teeth. Rotation of the forward splines resulted in rotation of the cooler fan and the aft splines. Several pieces of separated TRDS were also discovered in the debris field. Normally four hanger bearings are present on the TRDS on the tailboom. Only 3 bearings were recovered. On a typical installation, there was 1 steel TRDS segment between engine and oil cooler, then 5 aluminum TRDS segments between oil cooler and tail rotor. The 5 aluminum TRDS segments were supported by 4 hanger bearings. The aluminum TRDS are numbered 1 (forward-most TRDS) to 5 (aft-most TRDS). The steel TRDS was whole with evidence of heat stress, the forward end flex coupling was fractured, and the attaching hardware was present. The splines at the aft end of the steel TRDS did not show evidence of smearing or fractured teeth.

TRDS 1 was fractured about 1/3 its length from the aft end. The splines on the forward end of the TRDS were intact with no evidence of smearing or fracturing. The fracture location was in line with a main rotor blade strike line observed on the adjacent tailboom sheet metal. The aft end of the fracture exhibited heat damage. The aft flexible coupling was whole and exhibited serpentining and opening of the laminates.

TRDS 2 was fractured near its midpoint. The fracture location was in line with a main rotor blade strike line observed on the adjacent tailboom sheet metal. The aft flexible coupling was whole and it exhibited serpentining.

TRDS 3: only the forward riveted end cap was recovered. The rivets were fractured consistent with shear.

TRDS 4 was fractured about 2/3 of its length from the forward end, consistent with a main rotor blade strike of the tailboom. Only the aft end of the shaft was recovered. The aft flexible coupling had remained attached and exhibited opening of its laminates. Fractured attachment flanges from the aluminum TRDS 5, along with its attaching hardware, remained attached to the aft flexible coupling, and the attachment flange fractures exhibited overload signatures.

TRDS 5 and its aft flexible coupling were intact, did not exhibit evidence of damage, and remained attached to the tail rotor gear box (TRGB) input flange.

Examination of the TRGB revealed, that it had remained firmly attached to the structure. Manual rotation of the input flange resulted in a corresponding rotation of the tail rotor. The oil sight gage revealed the presence of oil within the gearbox. The chip detector was removed and revealed no evidence of chips or debris.

The tail rotor, which was still installed on the aft portion of the tail boom, came to rest in the top of a tree. Examination of the tail rotor revealed that, both blades (white and red) remained attached, and the tail rotor rotated freely with no evidence of binding. The white tail rotor blade displayed damage to the tip, consistent with contacting the left side of the tail boom. Its leading edge also displayed a damaged area about 3 inches wide about 15.5 inches inboard from the tip. The red tail rotor blade did not exhibit any anomalous damage.

Examination of the engine revealed that hard body foreign object damage was present on the first stage compressor blades, consistent with the engine operating at the time of the accident. The combined engine oil and fuel filter was present but found loose within the wreckage. The filter elements were present, but the aluminum filter bowls were missing with evidence of melting and were not recovered. The left engine mount was fractured from the structure, and the engine was laying on its right side. Residual oil observed within gearbox was tarred, the oil from the top was bright brown in color. The gearbox chip detectors when examined revealed that the upper and lower chip detectors were missing their magnet. Manual rotation of the first stage compressor resulted in rotation of the gears and the spline to the turbine. The electronic control unit (ECU) was found loose in the wreckage with one of its electrical connectors connected. The ECU exhibited thermal damage from exposure to the postcrash fire.

Examination of the flight controls revealed that the three main actuators were in the debris at the main accident site near their normally installed locations. One of the actuators consisted of only the piston, and the body had been consumed by fire. The tail rotor control tube was continuous from the tail rotor to the tail boom aft section, where the tailboom had fractured and separated. Manual movement of the tail rotor control tube resulted in pitch change of the tail rotor blades with no evidence of binding.

The tail rotor PCLs were intact and exhibited slight bending near the rod ends. Witness marks near the upper rod ends of the tail rotor PCLs were consistent with the rods contacting the outboard washer weights. The stationary swashplate for the right cyclic arm was fractured, and the collective lever was attached but fractured at its lower clevis. The rotating swashplate PCL arms for the red and orange main rotor blades were fractured, consistent with overload and thermal damage. The orange blade rotating swashplate PCL arm was found loose in the recovered main wreckage debris. The two PCL lower rod ends, with attaching hardware present, were recovered loose in the recovered main wreckage debris. The swashplate drive levers were present, and the drive lever between the blue and the orange blade was fractured with heat distress. The non-rotating swashplate anti-drive upper lever was melted, while the lower lever was present. A rod end consistent with the left cyclic upper rod end for the stationary swashplate was found loose in the recovered main wreckage debris.

The bellcranks between the main rotor servos and the stationary swashplate were found loose in the wreckage and contained clevis connections with the attaching hardware. The tail rotor push-pull tube was fractured at the tailboom to main fuselage interface. The push-pull tube was continuous to the idler link above the servo. Control continuity was established up to the
servo. At the forward end of the servo, the connections from the sides of the servo to the connecting link (at the forward end) were fractured and melted. The servo exhibited thermal damage.

A remnant of the push-pull tube for tail rotor control was observed underneath the transmission deck. The tube exhibited a fracture at the aft end with thermal damage. The tube was continuous under the transmission deck and thermally damaged and fractured at its forward end.

The right (pilot) side cyclic pitch control and collective pitch control were found in the remains of the cockpit. The cyclic pitch control grip was melted, but the stick was still connected at the base. The collective pitch control was disconnected, and fractured near its base. The left (observer) and right collective stick attachment points remained connected to the collective jackshaft, which was connected to the mixing unit. The left and right cyclic attachment points remained connected to the lateral jackshaft. The lateral push-pull tube was thermally damaged and had a small fracture on a portion of its tube, but was continuous. The lower portion of the left cyclic vertical push-pull tube (going up to the servo) rod end was connected at the mixer, but its tube was fractured and thermally damaged. The remainder of the tube was not observed. The lower portion of the collective vertical push-pull tube was fractured at the thread end of the tube. The remainder of the tube was not observed. The lower portion of the right cyclic vertical push-pull tube was fractured above the rod end threads. The tube showed evidence of impact marks. The remainder of the tube was not observed.

Control continuity was established between the cyclic pitch control to the mixing unit. The tail rotor fore-aft push-pull tube (routed under collective stick) was continuous back to the bellcrank (underneath the mixing unit). The bellcrank was attached to the structure, and the vertical push-pull tube was fractured at the lower rod end threads. The vertical push-pull tube exhibited thermal damage. The fore-aft push-pull tube was continuous up to the forward bellcrank. The lateral push-pull tubes from the left and right pedal sets were connected to the forward bellcrank.

The pedal travel limiter was installed but exhibited impact damage to its lower surface, and the cam was present. The pedal travel limiter emergency release was found in the cockpit but was thermally damaged. The copper safety wire remained intact.

The right pedal set was loose in the wreckage. The lateral push-pull tube was fractured in overload. The left pedal set remained installed in the cockpit but its lateral push-pull tube was fractured in overload. The pedals were consistent with being "locked out," and the left seat cyclic pitch control, and collective pitch control were found in the rear baggage compartment as required by VSP when an observer was seated in the left seat.

During the examinations, no evidence was observed to suggest that the accident was the result of a mid-air collision involving another aircraft, animal, or object.

The wreckage was retained by the National Transportation Safety Board for further examination.

According to FAA airworthiness records and helicopter maintenance records, the helicopter was manufactured in 2000. The helicopter's most recent 100-hour inspection was completed on August 3, 2017. At the time of the accident, the helicopter had accrued approximately 6,000 total hours of operation.

The pilot, a VSP Lieutenant, joined the aviation unit in 1999. In December 2012, he became the commander of the aviation unit. According to FAA airman and pilot records, he held an airline transport pilot certificate with a rating for rotorcraft-helicopter, as well as a commercial pilot certificate with ratings for airplane single-engine land, airplane multi-engine land, and instrument airplane. He also held a flight instructor certificate with ratings for airplane single-engine, airplane multi-engine, rotorcraft-helicopter, instrument airplane, and instrument helicopter. He also possessed a remote pilot certificate with a rating for small unmanned aircraft systems. He had accrued approximately 5,831 total hours of flight time, 2,704.6 of which were in helicopters. His most recent FAA second-class medical certificate was issued on August 19, 2016.

The observer, a VSP Trooper, joined the aviation unit in July 2017. According to FAA airman records, he held a private pilot certificate with a rating for airplane single-engine land. He had accrued approximately 97 total hours of flight time. His most recent FAA second-class medical certificate was issued on May 12, 2017.

The reported weather at CHO, located 7 nautical miles north-northeast of the accident site, at 1653, included: wind 190° at 6 knots, 10 statute miles visibility, with a thunderstorm in the vicinity, clear skies, temperature 30° C, dew point 22° degrees C, and an altimeter setting of 29.87 inches of mercury. 



Aircraft and Owner/Operator Information

Aircraft Manufacturer: BELL
Registration: N31VA
Model/Series: 407
Aircraft Category: Helicopter
Amateur Built: No
Operator: Virginia State Police
Operating Certificate(s) Held: None



Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: CHO, 644 ft msl
Observation Time: 1653 EDT
Distance from Accident Site: 7 Nautical Miles
Temperature/Dew Point: 30°C / 22°C
Lowest Cloud Condition: Clear
Wind Speed/Gusts, Direction: 6 knots, 190°
Lowest Ceiling: None
Visibility:  10 Miles
Altimeter Setting: 29.87 inches Hg
Type of Flight Plan Filed: None
Departure Point: CHARLOTTESVILLE, VA (CHO)
Destination: CHARLOTTESVILLE, VA (CHO) 



Wreckage and Impact Information


Crew Injuries: 2 Fatal

Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Fatal
Latitude, Longitude: 38.034167, -78.529444

Piper PA-32R-300 Cherokee Lance,  N5802V:  Fatal accident occurred May 08, 2015  near  Dekalb-Peachtree Airport (KPDK), Atlanta, Georgia





Family photo of Christopher Byrd and Jackie Kulzer just moments before they took off in Piper PA-32R-300 Cherokee Lance that crashed.


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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Atlanta, Georgia
Lycoming; Witchita, Kansas 
Piper; Vero Beach, Florida 

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


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


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


https://registry.faa.gov/N5802V




Location: Atlanta, GA
Accident Number: ERA15FA208
Date & Time: 05/08/2015, 0959 EDT
Registration: N5802V
Aircraft: PIPER PA-32R-300
Aircraft Damage: Destroyed
Defining Event: Loss of engine power (partial)
Injuries: 4 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal



Analysis


Several days before the accident flight, the commercial pilot told his mechanic and flight instructor that the airplane had not been climbing well. The pilot had completed an engine run-up and subsequent test flight, and found no anomalies with the airplane. The accident flight was the second leg of
a cross-country trip that originated earlier in the morning. During the accident takeoff, the pilot stated to air traffic control that the airplane was having trouble climbing. The airplane subsequently collided with terrain about 2 miles from the runway.

Postaccident testing of the fuel manifold showed that it was not operating normally and was contaminated with debris. The composition of debris and its origin could not be determined, but it was likely that the debris moved within the fuel manifold during operation and resulted in fluctuating power indications. Examination of the engine did not reveal any mechanical anomalies. Although the airplane was likely loaded 24 pounds in excess of its maximum gross weight, takeoff distance calculations showed that sufficient runway was available when loaded at the maximum gross weight for the departure and climb, assuming nominal performance of the airplane, engine, and pilot. Given that the airplane was having difficulty climbing, as communicated by the pilot to air traffic control during the departure, it is likely that during the takeoff, the debris in the fuel manifold prevented the engine from obtaining full power. 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
A partial loss of engine power due to contamination in the fuel manifold, which resulted in a collision with terrain shortly after takeoff.



Findings

Aircraft
Fuel - Fluid condition (Cause)
Fuel distribution - Not specified (Cause)

Factual Information

HISTORY OF FLIGHT

On May 8, 2015, about 0959 eastern daylight time, a Piper PA-32R-300, N5802V, collided with a highway barrier during a forced landing attempt near Chamblee, Georgia. The commercial pilot and three passengers were fatally injured and the airplane was destroyed. The airplane was registered to and operated by TLT and GGBB LLC., as a personal flight. Day, visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules (IFR) flight plan. The flight originated from Peachtree DeKalb airport (PDK), Chamblee, Georgia, about 0956 and was destined for University-Oxford Airport (UOX), Oxford, Mississippi.

The accident flight was the second leg of a cross-country flight that originated earlier that morning from Asheville Regional Airport (AVL), Asheville, North Carolina.

Review of air traffic control (ATC) voice communication data provided by the Federal Aviation Administration (FAA) revealed that the pilot contacted clearance delivery for an IFR clearance. ATC provided the clearance, which included radar vectors, and "climb and maintain 3,000; expect 8,000 in 10 minutes." The pilot read back the clearance correctly and confirmed that he had the most recent automatic terminal information service, which was information "Whiskey." The pilot contacted ground control and indicated that he was ready to taxi. Ground control instructed the pilot to taxi to runway 3R, via taxiway Bravo, hold short of runway 3L and the pilot read back the instructions correctly. The pilot then contacted the tower controller, informing him that he was holding short of runway 3L and ready to depart. The tower controller instructed the pilot to "fly heading 360 and cleared for takeoff." The pilot then questioned the controller regarding which runway to take off from and the controller cleared the pilot for takeoff from runway 3L, which was 3,746 feet long. Approximately 3 minutes after departure, the tower controller called the pilot to verify his heading. The pilot responded "zero-two-victor, I'm having some problem climbing here." The pilot subsequently stated "zero-two-victor; were going down here at the intersection." This was the last transmission made by the pilot.

A witness stated that he was about 2,300 feet off the departure end of the runway. He stopped to look at the airplane because it was moving extremely slow and only 75 to 100 feet above ground level when it went over his head. He added that the engine sounded normal and despite the slow speed. He continued to watch the airplane as it flew out of his view.

Another witness that observed the airplane prior to the accident said he heard a "clacking sound," but the engine rpm did not change. The engine sounded like it was at "wide open throttle" as it descended onto the highway and exploded.

According to the pilot's mechanic, about 4 days prior to the accident flight, the mechanic observed a departure conducted by the pilot. He said that during climbout he watched as the airplane cleared trees at the departure end of the runway by approximately 50 feet. He added that shortly after that flight, the pilot called him and expressed his concern that the airplane was not climbing well. The mechanic mentioned to him that it was a warm day, and he was only a few hundred pounds under gross weight, with a slight tailwind. The mechanic further stated that the pilot said that he would do a run-up and if everything checked out, he would conduct a test flight the next day. The following day the pilot sent a text message to the mechanic and said that the run-up was good, but he wasn't getting full rpm at full power while static. About 30 minutes later, the pilot called the mechanic and told him he flew the airplane and everything was normal.

According to pilot's flight instructor, he said that the pilot called him 4 days prior to the accident flight and told him that he went flying and had some difficulty getting the airplane to gain altitude. He said that he had used up more than half of the runway when he was able to finally get the airplane in the air. The pilot told the instructor that he almost hit the trees near the end of the runway. The pilot also stated to the flight instructor that he did conduct "pre and post flight engine checks and noted no problems."



PERSONNEL INFORMATION

The pilot held a commercial pilot certificate with ratings for airplane single-engine land and instrument airplane. He reported a total flight experience of 667 hours, including 40 hours during the last 6 months, on his FAA second-class medical certificate application, dated November 18, 2014. The medical certificate indicated no restrictions. Review of the pilot's logbook revealed he had accumulated 687 total hours; of which, 672 hours were in the same make and model as the accident airplane.

AIRCRAFT INFORMATION

The airplane was manufactured in 1977. It was powered by a Lycoming O-540-K1G5D engine rated at 300 horsepower at 2,700 rpm, and was equipped with a Hartzell three-bladed constant speed propeller.

The last annual inspection of the airframe and engine occurred on July 22, 2014, at an airframe total time of 5616.03 hours. The last recorded maintenance included the installation of a battery on May 5, 2015.

The airplane's maintenance logbooks were not located and were presumed to have burned in the aircraft wreckage. Copies of airframe and engine logbook entries dated July 22, 2014 were provided by the mechanic who completed an annual inspection of the airplane on that date. The airframe logbook entry noted the tachometer hour meter reading and airframe total time as 5616.03 hours. The engine logbook entry indicated that the engine had accumulated 774.86 hours since major overhaul, as of that date.



METEOROLOGICAL INFORMATION

The recorded weather at PDK, at 0953, included winds from 080 degrees at 4 knots; 6 statute miles visibility, few clouds at 6,000 feet, temperature 24 degrees Celsius (C), dew point temperature 16 degrees C, and an altimeter setting of 30.14 inches of mercury. The calculated density altitude was about 2,259 feet.

WRECKAGE AND IMPACT INFORMATION

The wreckage was located in the eastbound lane of interstate 285, approximately 2 miles from PDK. The airplane came to rest in the left service lane against a 5 foot barrier wall on a heading of 021 degrees magnetic. There was a postcrash fire that consumed the majority of the airplane. There were ground scars across four traffic lanes up to the concrete highway divider.

The cockpit and fuselage were fragmented and destroyed by postcrash fire. Flight control cables were attached to fragments of the flight controls. The right and left wings were fragmented and was destroyed by postcrash fire. The flight control surfaces were molten metal on both wings. The aileron bellcranks on the left and right wings were located within the fragments of the wings and connected to the flight control cables and turnbuckles. Flight control cable separations exhibited signs of overstress failures. The empennage was fragmented and fire damaged. The flight control cables to the rudder control sector and stabilator bell crank remained attached to the fragmented fuselage and were traced to the forward section of the cockpit.

The left and right main landing gear were found in the extended position and the flap handle was impact damaged and observed in the 10-degree flap extension position. The throttle was found forward in the "full power" position, the propeller lever was forward at the "full increase" position, and the mixture lever was full forward at the "full rich" position. The fuel boost pump switch and selector was destroyed. Engine control linkage continuity was established from the cockpit controls to their respective engine connections.

An examination of the fuel system revealed that the all of the fuel lines before the firewall were destroyed. The fuel lines from the firewall to the fuel manifold were partially fire damaged. The fuel manifold and injector lines did not show signs of fire damage. The fuel manifold was removed during the examination of the engine and placed on a test bench and did not flow when tested up to 7 psi (normal test pressure is 4.5 psi). The unit was removed from the test bench and the bottom cover was removed. Following removal of the bottom cover, the gasket did not exhibit heat damage. The bottom portion of the movable portion of the body assembly was measured and found to be positioned 0.032 inch below the spool of the body assembly (normal closed position). The bottom of the movable portion of the body assembly was pushed by hand and some resistance was noted at first, but it then moved. The bottom cover was reinstalled and the four screws were torqued to the proper setting. The fuel manifold was placed on the test bench and debris was noted coming from the ports during initial flow. The unit was flowed at 4.5 psi (normal) and it was found to flow equally from all ports at 132 pounds-per-hour (pph); the minimum specification was 135 pph. The fuel manifold was removed from the test bench and the top cover, which was safety wired, was removed. Test bench fluid was noted on the top side of the diaphragm (air side) and some slivers of material were also noted. The movable portion of the body assembly was removed and contamination/debris was noted. Re-insertion of the movable portion of the body assembly into the body revealed slight binding.

The debris recovered from the fuel manifold was forwarded to the NTSB Materials Laboratory and examined using Fourier-transform infrared spectroscopy. The spectrum for the debris contained peaks that corresponded to signatures indicative that the material contained a carboxylic acid. A spectral library search was done on the debris spectrum. There were no strong matches found in the search; however, the debris spectrum had many similarities to several dicarboxylic acids, such as terephthalic acid and isophthalic acid. Carboxylic acids are pervasive in nature and are often found as precursors in polymer production, in adhesives and coatings, and are often naturally present in fuel as well as used as fuel additives (corrosion inhibitors and lubricity improving additives).

During examination of the fuel servo, it was noted that it was fire damaged. Due to the heat damage of the diaphragms, the unit could not be flow tested.

Examination of the propeller revealed that one blade was fractured off the hub. The spinner dome separated from the spinner bulkhead. All three blades exhibited rotational scoring and curling of the blade tips. There were impression marks on the preload plates indicating that the propeller was in the low blade angle position prior to impact. The propeller showed signs of power ON prior to impact. There were no discrepancies noted that would preclude normal operation. All damage was consistent with impact damage.

The propeller governor was mounted in a governor test stand and run through the standard factory acceptance test procedure for new or overhauled governors. The governor functioned normally and met all factory specifications, except for the maximum rpm. The governor maximum rpm setting was 2,660 rpm verses a factory specification of 2,555 +/- 10. Although the high rpm setting was higher than factory specifications, it did not affect the governor performance. A higher than specified rpm setting indicated an adjustment was made to the governor high rpm stop while installed on the airplane. The governor was then disassembled for visual examination of the governor components. There were no unserviceable conditions noted during the visual examination.

Examination of the engine revealed it was discolored consistent with exposure to the postimpact fire. The propeller and crankshaft flange were separated from the engine. The crankshaft flange was impact damaged. The left side of the exhaust system was crushed. The engine accessories were fire damaged. Both crankcase halves were fractured in the area of the No. 1 and No. 2 cylinders. The No. 2 cylinder head on the left side was impact damaged. The engine mount was bent and the engine was displaced toward the firewall. Three of the four engine mounts were impact fractured. The engine could not be rotated by turning the crankshaft flange due to impact damage and was further disassembled to examine the engine internal components. The cylinders were removed and no damage noted to the cylinders, pistons or valves other than fire and impact damage. The oil sump was removed and contained an unmeasured quantity of oil. The accessory case was removed and no damage to the rear gears was noted. The oil pump was disassembled and no damage to the pump bore or gears was noted. The crankcase halves were disassembled and the crankshaft and rod assembly was lifted out. The rods were free to rotate on the crankshaft rod journals and were not disassembled. The crankshaft main journals and crankshaft bearing surfaces did not show any anomalies. The camshaft was removed and no damage noted to the crankcase camshaft bearing surfaces. No damage was noted to the camshaft except that the cam lobe, which serviced the No. 3 intake and the No. 4 exhaust cam followers were worn. The cam lobe was measured at 1.364 inches using an uncalibrated dial caliper. The No. 4 exhaust lobe was measured at 1.464 inches. The No. 3 intake and No. 4 exhaust cam followers were pitted and worn.



MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot by the DeKalb County Medical Examiner, Decatur Georgia.

The Federal Aviation Administration's Civil Aerospace Medical Institute performed forensic toxicology on specimens from the pilot with negative results for drugs and alcohol.

ADDITIONAL INFORMATION

The weight and balance record dated August 24, 1999, noted the airplane's empty weight to be 2,154 lbs. According to the Pilot Operating Handbook (POH) the maximum takeoff and landing weight for this aircraft was 3,600 lbs. With full fuel (94 gallons useable), an estimated cargo weight of 216 lbs, and reported pilot and passengers weights of 690 lbs, the total weight computed was 3,624 lbs. According to fueling records the airplane was topped off with 20 gallons of fuel prior to departure. The estimated cargo weight was based on the fire damaged items that were collected during the airplane recovery.

The airplane's calculated takeoff distance assuming that it was loaded to its maximum gross weight, the flaps were set to 25 degrees, and given the weather conditions reported about the time of the accident, was about 1,050 feet. The distance required to clear a 50-foot barrier was about 2,000 feet.

History of Flight

Initial climb
Loss of engine power (partial) (Defining event)

Emergency descent
Off-field or emergency landing
Collision with terr/obj (non-CFIT)

Pilot Information

Certificate: Commercial
Age: 53, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 2 Without Waivers/Limitations
Last FAA Medical Exam: 11/18/2014
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time:  (Estimated) 687 hours (Total, all aircraft), 672 hours (Total, this make and model)

Aircraft and Owner/Operator Information

Aircraft Make: PIPER
Registration: N5802V
Model/Series: PA-32R-300
Aircraft Category: Airplane
Year of Manufacture:
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 32R-7780365
Landing Gear Type: Retractable - Tricycle
Seats: 6
Date/Type of Last Inspection: 07/22/2014, Annual
Certified Max Gross Wt.: 3600 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 5616.03 Hours as of last inspection
Engine Manufacturer: Lycoming
ELT: C91  installed, not activated
Engine Model/Series: O540-K1G5D
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: Day
Observation Facility, Elevation: PDK, 998 ft msl
Distance from Accident Site: 2 Nautical Miles
Observation Time: 0953 EDT
Direction from Accident Site: 160°
Lowest Cloud Condition: Few / 6000 ft agl
Visibility:  6 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 4 knots /
Turbulence Type Forecast/Actual: /
Wind Direction: 80°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 30.14 inches Hg
Temperature/Dew Point: 24°C / 16°C
Precipitation and Obscuration: Moderate - Haze
Departure Point: Atlanta, GA (PDK)
Type of Flight Plan Filed: IFR
Destination: OXFORD, MS (UOX)
Type of Clearance: IFR
Departure Time: 0956 EDT
Type of Airspace: Class D

Airport Information

Airport: Dekalb-Peachtree Airport (PDK)
Runway Surface Type:
Airport Elevation: 998 ft
Runway Surface Condition: Dry
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: Forced Landing

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 3 Fatal
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: On-Ground
Total Injuries: 4 Fatal
Latitude, Longitude: 33.891111, -84.272778 (est)

Piper PA-46-500TP Meridian, N891CR: Fatal accident occurred December 24, 2015 near Roscoe Turner Airport (KCRX), Corinth, Alcorn County, Mississippi


Lauren Chase

Lauren Chase, 32, pictured on her wedding day with her husband David, died eight months after suffering severe brain injuries in a Piper PA-46-500TP Meridian crash. 

Mrs. Lauren Chase

Mrs. Lauren Chase, pictured after the accident, was left paralyzed and in a vegetative state when the Piper PA-46-500TP Meridian crashed in Corinth, Mississippi on December 24th, 2015.

Suffering horrific injuries, Mrs. Chase spent the last few months of her life in hospital with her family members by her side, who then took the heartbreaking decision to withdraw treatment so she could be 'free again'. 


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

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Jackson, Mississippi 
Piper Aircraft; Vero Beach, Florida 
Pratt & Whitney Canada; Montreal 
Transportation Safety Board of Canada; Ottawa

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

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

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

http://registry.faa.gov/N891CR 



Location: Corinth, MS
Accident Number: ERA16LA078
Date & Time: 12/24/2015, 0840 CST
Registration: N891CR
Aircraft: PIPER AIRCRAFT INC PA-46
Aircraft Damage: Substantial
Defining Event: Loss of control in flight
Injuries: 2 Serious, 2 Minor
Flight Conducted Under: Part 91: General Aviation - Personal

Analysis 

On the day of the accident, a line service technician had disconnected the airplane from a battery charger. After disconnecting the battery, he left the right access door open which provided access to the fuel control unit, fuses, fuel line, oil line, and battery charging port as he always did. He then towed the airplane from the hangar it was stored in, and parked it in front of the airport's terminal building.

The three passengers arrived first, and then about 30 minutes later the pilot arrived. He uploaded his navigational charts and did a preflight check "which was normal." The engine start, taxi, and engine run up, were also normal. The wing flaps were set to 10°. After liftoff he "retracted the landing gear" and continued to climb. Shortly thereafter the right cowl door opened partially, and started "flopping" up and down 3 to 4 inches in each direction. He reduced the torque to try to prevent the right cowl door from coming completely open. However, when he turned on the left crosswind leg to return to the runway, the right cowl door opened completely, and the airplane would not maintain altitude even with full power, so he "put the nose back down." The airplane struck trees, and then pancaked, and slid sideways and came to rest, in the front yard of an abandoned house.

The private pilot and one passenger received minor injuries. Two passengers received serious injuries, one of whom was found out of her seat, unconscious, on the floor of the airplane shortly after the accident, and died about 227 days later. During the investigation, it could not be determined, if she had properly used the restraint system, as it was found unlatched with the seatbelt portion of the assembly extended.

Examination of the wreckage revealed no evidence of any preimpact failures or malfunctions of the airplane or engine that would have precluded normal operation. It was discovered though, that the right access door had not been closed and latched by the pilot before takeoff, as examination of the right access door latches and clevis keepers found them to be functional, with no indication of overstress or deformation which would have been present if the access door had been forced open due to air loads in-flight, or during the impact sequence. Further examination also revealed that the battery charging port cover which was inside the compartment that the right access door allowed access to, had not been placed and secured over the battery charging port, indicating that the preflight inspection had not been properly completed.

A checklist that was provided by a simulator training provider was found by the pilot's seat station. Examination of the checklist revealed that under the section titled: "EXTERIOR PREFLIGHT" only one item was listed which stated, "EXTERIOR PREFLIGHT…COMPLETE." It also stated on both sides of the checklist: "FOR SIMULATOR TRAINING PURPOSES ONLY." A copy of the airplane manufacturer's published pilot's operating handbook (POH) was found in a cabinet behind the pilot's seat where it was not accessible from the pilot's station. Review of the POH revealed that it contained detailed guidance regarding the preflight check of the airplane.

Additionally, it was discovered that the landing gear was in the down and locked position which would have degraded the airplane's ability to accelerate and climb by producing excess drag, and indicated that the pilot had not retracted the landing gear as he thought he did, as the landing gear handle was still in the down position. Review of recorded data from the airplanes avionics system also indicated that the airplane had roughly followed the runway heading while climbing until it reached the end of the runway. The pilot had then entered a left turn and allowed the bank angle to increase to about 45°, and angle of attack to increase to about 8°, which caused the airspeed to decrease below the stalling speed (which would have been about 20% higher than normal due to the increased load factor from the steep turn) until the airplane entered an aerodynamic stall, indicating that the pilot allowed himself to become distracted by the open door, rather than maintaining control of the airplane.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be: 
The pilot's inadequate preflight inspection and his subsequent failure to maintain airplane control, which resulted in an access door opening after takeoff, and the airplane exceeding its critical angle of attack and experiencing an aerodynamic stall.

Findings

Aircraft
Service doors - Not inspected (Cause)
Service doors - Malfunction (Cause)
Performance/control parameters - Not attained/maintained (Cause)
Airspeed - Not attained/maintained (Cause)
Angle of attack - Capability exceeded (Cause)

Personnel issues
Preflight inspection - Pilot (Cause)
Forgotten action/omission - Pilot (Cause)
Decision making/judgment - Pilot (Cause)
Incorrect action performance - Pilot (Cause)
Aircraft control - Pilot (Cause)

Factual Information

History of Flight

Prior to flight
Preflight or dispatch event

Takeoff
Miscellaneous/other

Initial climb
Attempted remediation/recovery
Loss of control in flight (Defining event)

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

Post-impact
Fire/smoke (post-impact) 



On December 24, 2015, about 0840 central standard time, a Piper PA-46-500TP, N891CR, impacted a tree and terrain during a return to the airport after takeoff from Roscoe Turner Airport (CRX), Corinth, Mississippi. The private pilot and one passenger received minor injuries. Two passengers received serious injuries, one of whom died 227 days after the accident due to her injuries. The airplane sustained substantial damage. The airplane was registered to North Mississippi Pulmonology Clinic, Inc., and was operated by the pilot under Title 14 Code of Federal Regulations (CFR) Part 91. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed for the cross-country personal flight that was destined for Ocean Reef Club Airport (07FA), Key Largo, Florida.

According to a line service technician at the airport, when he arrived at work on the day of the accident, he received a note stating that the airplane had been previously fueled. He then went to the hangar where the airplane was kept, unplugged the airplane from the battery charger, towed the airplane to the terminal, and parked the airplane so it was parallel to the front of the terminal. The line service technician reported that, when he unplugged the airplane from the battery charger, he did not close the right access door (located behind the engine and forward of the right-wing root), which provided access to the battery charging port. The technician stated that he left the door in the open position, that they would not open or close doors on an aircraft unless requested to, and that he had advised the pilot of this in the past.

The pilot's wife, daughter, and daughter-in-law arrived at the airport about 30 minutes before the pilot, as the pilot had to go to his office first. When the pilot arrived, he told the line service technician, "I'll see you." About 20 minutes later, the line service technician heard the engine start, and then he heard the airplane taxi to runway 18 and takeoff. The line service technician stated that it sounded to him like the airplane's engine was producing full power when the airplane took off. A little while later, the telephone rang, and he was advised that the airplane had crashed.

According to the pilot, he arrived at the airport about 0800, uploaded his navigational charts, and did a preflight check, which was normal. The pilot stated that the airplane's battery was on a trickle charger the night before the flight, which required that the right access door be open, but that he checked the door during his preflight check and secured it. The engine start, taxi, and engine run up were normal. They departed from runway 18 with the wing flaps set to 10°. Rotation for takeoff was at 85 knots indicated airspeed with power set to 1,240 ft-pounds of torque. After liftoff, he retracted the landing gear and continued to climb. Shortly thereafter, the right access door opened partially and started "flopping" up and down 3 to 4 inches in each direction. He reduced the torque to 900 ft-pounds to try to prevent the right access door from coming completely open and attempted to return to the airport. However, when he turned on the left crosswind leg for runway 18, the right access door opened completely, and the airplane would not maintain altitude even with full power, so he "put the nose back down." The airplane then hit a treetop and came to rest in the front yard of an abandoned house.

According to a witness, who was an airplane mechanic employed at the airport, he was driving past the south end of the runway, when he saw the airplane about 150 ft above ground level flying "real slow." It flew over Highway 2, and its wings were "wagging" like it was going to stall. The left wing "dropped," and the airplane "fell" through some trees, "pancaked," and then slid sideways.

Review of data recovered from the airplane's Avidyne Entegra avionics system indicated that, after becoming airborne, the airplane roughly followed the runway heading while climbing until it reached the end of the runway. The airplane then entered a left turn, and the airspeed, which had reached a maximum of about 102 knots began to decrease. At 0839:57, the airplane was at a pressure altitude of 507 ft. At this point, the airspeed had dropped to about 80 knots, and the airplane was in a left bank of about 45°. The recorded data ended about 60 seconds before impact because the system did not have time to write the buffered data to the system's memory card before the unit lost power.

According to the pilot, when the airplane came to a stop, the left wing was burning. The pilot told his daughter to get out of the airplane, which she did. His wife and daughter-in-law were both unconscious, so he asked his daughter to help him get them out. They got his daughter-in-law out first and then his wife, who was conscious by then.

When the witness got to the airplane, there was a small fire coming from the left wing. The pilot had already egressed, and his daughter was in the process of exiting the airplane. The pilot's daughter-in-law was laying on the floor of the airplane between the middle and aft rows of seats. The witness picked her up and laid her down by the road in front of the house. The pilot then went back into the airplane to get his wife out. She had facial injuries, and the witness helped to get her out of the airplane by kicking open the lower cabin door, grabbing her by her hands, and dragging her out of the airplane. 

Pilot Information

Certificate: Private
Age: 63, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 3 Without Waivers/Limitations
Last FAA Medical Exam: 06/17/2015
Occupational Pilot: No
Last Flight Review or Equivalent: 08/19/2015
Flight Time:  1990 hours (Total, all aircraft), 427 hours (Total, this make and model), 1628 hours (Pilot In Command, all aircraft), 12 hours (Last 90 days, all aircraft), 2 hours (Last 30 days, all aircraft) 

According to Federal Aviation Administration (FAA) airman records, the pilot held a private pilot certificate with ratings for airplane single-engine land, airplane multi-engine land, and instrument airplane. He held an FAA third-class medical certificate dated June 17, 2015, with no limitations. The pilot reported that he had accrued about 1,990 total hours of flight experience, of which 427 hours were in the accident airplane make and model.

Aircraft and Owner/Operator Information

Aircraft Make: PIPER AIRCRAFT INC
Registration: N891CR
Model/Series: PA-46 500TP
Aircraft Category: Airplane
Year of Manufacture:
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 4697321
Landing Gear Type: Retractable - Tricycle
Seats: 6
Date/Type of Last Inspection: 10/01/2015, Annual
Certified Max Gross Wt.: 4850 lbs
Time Since Last Inspection: 16 Hours
Engines: 1 Turbo Prop
Airframe Total Time: 1407 Hours at time of accident
Engine Manufacturer: P&W CANADA
ELT: C126 installed, not activated
Engine Model/Series: PT6A-42A
Registered Owner: NORTH MISSISSIPPI PULMONOLOGY CLINIC INC
Rated Power: 500 hp
Operator: On file
Operating Certificate(s) Held:  None 

The airplane was a high-performance, single-engine, pressurized, six-place, low-wing monoplane certificated in the normal category. It was equipped with retractable landing gear and wing flaps. It was powered by a 500-shaft horsepower, Pratt & Whitney Canada PT6A-42A turboprop engine, driving a 4-bladed, hydraulically actuated, constant-speed, full-feathering, reversible-type propeller. The airplane was certificated for flight in visual, instrument, day, night, and icing conditions.

According to FAA airworthiness records and airplane maintenance records, the airplane was manufactured in 2007. Its most recent annual inspection was completed on October 1, 2015. At the time of the accident, the airplane had accrued about 1,407 total hours of operation.

The unpressurized nose section included the engine compartment and nose landing gear assembly. The engine compartment contained the powerplant and associated accessories. The forward section of the engine compartment was enclosed by a two-piece nose cowl. Aft of the nose cowl, two hinged access doors (also identified as "cowl doors" or "gull wing doors" in the airplane manufacturer's various documents) provided servicing and inspection access to components in the aft engine compartment. The left access door provided access to the engine oil sight gauge and the brake fluid reservoir. The right access door provided access to the fuel control unit, fuses, fuel line, oil line, and the battery charging port.

The access doors were attached to the airplane structure with piano-type hinges and secured with latches. Once opened, each door was held in the open position by a support rod with a "twist-lock" mechanism. The doors were closed by slightly lifting on the door, then unlocking the mechanism by twisting the upper part of the support rod a quarter-turn while holding the lower part of the support rod. Once the mechanism was unlocked, the door could be lowered into the closed position and latched.

Review of flight test data for the PA-46-500TP indicated that at 0° of bank (1G), the airplane would stall at 79 knots indicated airspeed (KIAS) with the landing gear down and the wing flaps set at 10°. With the airplane in the same configuration in a 45° bank (about 1.4G), the stall speed would be about 95 KIAS (about 20% higher).

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: CRX, 424 ft msl
Distance from Accident Site: 1 Nautical Miles
Observation Time: 0840 CST
Direction from Accident Site: 360°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 4 knots /
Turbulence Type Forecast/Actual: / None
Wind Direction: 100°
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 29.98 inches Hg
Temperature/Dew Point: 15°C / 11°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Corinth, MS (CRX)
Type of Flight Plan Filed: None
Destination: KEY LARGO, FL (07FA)
Type of Clearance: None
Departure Time: 0835 CST
Type of Airspace: Class G 

The reported weather at CRX, at 0915, included wind 100° at 4 knots, 10 miles visibility, clear skies, temperature 15°C, dew point 11°C, and an altimeter setting of 29.98 inches of mercury. 

Airport Information

Airport: ROSCOE TURNER (CRX)
Runway Surface Type: Asphalt
Airport Elevation: 424 ft
Runway Surface Condition: Dry
Runway Used: 18
IFR Approach: None
Runway Length/Width: 6500 ft / 100 ft
VFR Approach/Landing: None 

CRX is a non-towered, publicly-owned airport located 4 miles southwest of Corinth, Mississippi. The airport elevation is about 425 ft above mean sea level, and there is one runway oriented in a 18/36 configuration. Runway 18 is asphalt, grooved, marked with precision markings, and measures 6,500-ft-long by 100-ft-wide.

Wreckage and Impact Information

Crew Injuries: 1 Minor
Aircraft Damage: Substantial
Passenger Injuries: 2 Serious, 1 Minor
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Serious, 2 Minor
Latitude, Longitude: 34.902778, -88.598056 (est) 

The airplane came to rest about 1,792 ft from the departure end of runway 18 on a 132° magnetic heading on the front lawn of a residence. Examination of photographs of the wreckage taken at the accident site revealed that the right cowl door was open (see Figure 1).

Figure 1 –Right Side Access Door

Wreckage Examination

Examination of the wreckage revealed that during the impact sequence the nose landing gear was separated from the airframe. The nose gear actuator was found in the down and locked position. The firewall was separated from the forward pressure bulkhead.

The tail section of the aircraft from fuselage station 249.60 to station 326.05 was impact-damaged and crushed downward.
The pilot's side window was fire damaged, and the window just aft of the pilot's side window was also fire damaged and was partially separated from the window frame. The fuselage was accordion-crushed forward and down between the pilot's side window and the number three window. The bottom of the fuselage was crushed upward into the cabin floor.

The top engine cowl had separated from the airframe and was impact-damaged. The top engine cowl mounting points were separated from the cowl on the right side and remained attached to the airframe and bottom cowl.

The left access door was found separated from its mounting points. The hinges were found to be bent forward, and the forward clevis keeper was pulled upward deforming its mounting area.

The right access door was found open and unlatched with minimal damage noted to the door. The right access door support rod was found lying on top of the battery bay, and the battery charging port cover was not installed over the charging port. A functional check of the right access door latches found them to be functional with no indication of overstress or deformation, and there was no deformation or indication of overstress to the clevis keepers.

The rudder and rudder trim tab remained attached to the vertical fin. The rudder was impact damaged on the bottom right side. The rudder skin was crushed down along the entire span of the rudder; the top rudder attach point was partially separated from the vertical fin; and the rudder torque tube remained attached to the rudder bellcrank. The rudder trim actuator was extended about 1.5 inches, which indicated a neutral to slight-nose-right trim setting.

The elevator and elevator trim tab remained attached to the horizontal stabilizer. The left and right sides of the horizontal stabilizer had leading edge impact damage. The aft spar of the horizontal stabilizer was separated from the remainder of the structure.

The elevator pitch torque tube remained attached to the elevator and to mounting area of the pitch sector. The elevator trim rods remained attached to the elevator trim tab, but the rod ends were found to be fragmented from the elevator trim barrel assembly. The elevator trim barrel remained attached to the fuselage and had three threads exposed on the leading edge of the trim barrel, which indicated a neutral to slight-nose-down elevator trim setting.

The left wing had fire damage to the outboard wing section from wing station 220.00 to the wing tip. Fire damage was also noted between wing stations 71.00 and 134.00. The left main landing gear was fire damaged but had remained attached to its mounts; the left main landing gear actuator was found in the down-and-locked position. The left aileron remained attached to the wing, and about 12 inches of the outboard side had been consumed by fire.

The left flap separated at the inboard and center attaching points but remained partially attached to the outboard attaching point. Fire damage to the flap was noted between wing stations 82.50 and 116.00. Impact damage was noted within the outboard section of the flap. Examination of the flap motor jack screw indicated that the wing flaps were in the 10° position.

The right wing had leading edge damage to the entire span of the wing; circular leading edge damage was noted inboard of the recognition light. The right main landing gear door was impact damaged. The right main landing gear remained attached to the wing, and the right main landing gear wheel assembly, scissor link, and strut tube were separated. The right main landing gear actuator was observed to be in the down and locked position. The right flap and the right aileron remained attached to their mounts

Control continuity was established from all the flight control surfaces to the breaks and cuts in the system and from the breaks and cuts in the system to the cockpit.

The bleed air switch was in the "ON" position. The power lever was in the "FULL" position. The condition lever was in the "RUN" position. The manual override was in the "OFF" (stowed) position. The fuel shutoff valve was stowed. The landing gear selector was found in the down position. The wing flap lever was set to 10°.

The pilot's and copilot's seats were undamaged, and a functional check of the seat stops of both seats revealed no anomalies. The pilot's and copilot's seat belts were examined and found to be functional. The left and right center row seats were undamaged, and their seat belts were functional. The left and right aft row seat backs were found canted inward and aft. The seat back stops were in place and operational. The left aft seat belt was found unlatched, and the seat belt was extended. Functional checks of the aft seat belts found them to be operational.



Engine Examination

The spinner was impact damaged and crushed aft. The propeller blades exhibited chordwise scratching, and three of the four blades were bent aft mid span about 90°. The fourth blade was twisted about midspan.

The power lever cable remained attached to the cam assembly; the condition lever cable remained attached to the control arm; and the manual override cable remained attached to the fuel control unit. All the engine fuel lines remained intact and were attached to their respective fittings. The engine displayed impact damage including compressional deformation of the exhaust duct.

Strong circumferential contact signatures were displayed by the compressor 1st stage blades and shroud; compressor turbine vane ring and turbine; power turbine 1st stage vane ring, shroud, and turbine; and power turbine 2nd stage shroud and turbine, which was consistent with them making contact under impact loads and external housing deformation.

None of the engine mechanical components displayed any indications of any preimpact anomalies or distress. 

Medical And Pathological Information

On August 7, 2016, the pilot's daughter-in-law, who had been seated in the left seat of the aft row, died. According to the Harris County Institute of Forensic Sciences, Houston, Texas, the daughter-in-law's cause of death was complications of subdural hemorrhage due to blunt force head injuries. 

Tests And Research

The mechanic witness reported that he had seen the airplane in the hangar many times and that the right access door was always open, as the airplane was always hooked up to a battery cart.

Checklists

During the wreckage examination, a checklist that was provided by a simulator training provider was found on the floor by the pilot's rudder pedals. Examination of the checklist revealed that the section titled "EXTERIOR PREFLIGHT" only listed one item, which stated, "EXTERIOR PREFLIGHT…COMPLETE." Both sides of the checklist stated, "FOR SIMULATOR TRAINING PURPOSES ONLY."

A copy of the airplane manufacturer's published pilot's operating handbook (POH) was found in the cabinet behind the pilot's seat, a location that was not accessible from the pilot's station. Review of the POH revealed that it contained detailed guidance regarding the preflight check of the airplane. One item in the "Preflight Checklist" stated, "Right Cowl Door…OPEN-CHECK GENERAL CONDITION-SECURE DOOR."

Under "AMPLIFIED NORMAL PROCEDURES," the POH stated that, during the preflight check, the pilot should "open the right side cowling door and check general condition of the linkage, hoses, and wiring, then close and secure the door." 



Additional Information

Airplane Flying Handbook

Under the heading, "Door Opening In-Flight," the FAA's Airplane Flying Handbook (FAA-H-8083-3B) states: In most instances, the occurrence of an inadvertent door opening is not of great concern to the safety of a flight, but rather, the pilot's reaction at the moment the incident happens. A door opening in flight may be accompanied by a sudden loud noise, sustained noise level, and possible vibration or buffeting. If a pilot allows himself or herself to become distracted to the point where attention is focused on the open door rather than maintaining control of the airplane, loss of control may result even though disruption of airflow by the door is minimal."

The handbook explains that, in the event of an inadvertent door opening in flight or on takeoff, the pilot should concentrate on flying the airplane. It states that "there may be some handling effects, such as roll and/or yaw, but in most instances, these can be easily overcome." It further states that, "if a door opens after lift off, do not rush to land. Climb to normal traffic pattern altitude, fly a normal traffic pattern, and make a normal landing."

The handbook cautions that "attempting to get the airplane on the ground as quickly as possible may result in steep turns at low altitude." It further cautions the pilot to complete all items on the landing checklist and to "remember that accidents are almost never caused by an open door. Rather, an open door accident is caused by the pilot's distraction or failure to maintain control of the airplane."

Aerodynamic Stalls

The Airplane Flying Handbook, also contained information regarding aerodynamic stalls, advising that, at low angles of attack (AOA), the airflow over the top of the wing flows smoothly and produces lift with a relatively small amount of drag. As the AOA increases, lift as well as drag increases; however, above a wing's critical AOA, the flow of air separates from the upper surface and backfills, burbles and eddies, which reduces lift and increases drag. This condition is a stall, which can lead to loss of control if the AOA is not reduced.

The handbook further advised that, it is important for the pilot to understand that a stall is the result of exceeding the critical AOA, not of insufficient airspeed. The term "stalling speed" can be misleading, as this speed is often discussed when assuming 1G flight at a particular weight, and configuration. Increased load factor directly affects stall speed (as well as do other factors such as gross weight, center of gravity, and flap setting). Therefore, it is possible to stall the wing at any airspeed, at any flight attitude, and at any power setting. For example, if a pilot maintains airspeed and rolls into a coordinated, level 60° banked turn, the load factor is 2Gs, and the airplane will stall at a speed that is 40 percent higher than the straight-and-level stall speed. In that 2G level turn, the pilot must increase AOA to increase the lift required to maintain altitude. At this condition, the pilot is closer to the critical AOA than during level flight and therefore closer to the higher speed that the airplane will stall at. Because "stalling speed" is not a constant number, pilots must understand the underlying factors that affect it to maintain aircraft control in all circumstances.



Use of Seatbelts and Shoulder Harnesses

According to the CFRs, the regulations give the pilot in command two tasks regarding seat belts and shoulder harnesses.

The first is to brief the passengers on how the seat belts work:

...the pilot in command of that aircraft ensures that each person on board is briefed on how to fasten and unfasten that person's seat belt and, if installed, shoulder harness. (14 CFR 91.107(a)(1)).

The second is to notify the passengers that seat belts must be fastened:


...the pilot in command of that aircraft ensures that each person on board has been notified to fasten his or her safety belt and, if installed, his or her shoulder harness. (14 CFR 91.107(a)(2).)

The POH, also provided guidance under "NORMAL PROCEDURES," on the "BEFORE STARTING ENGINE CHECKLIST.":

"Seat Belts and Harness…FASTEN / ADJUST – CHECK inertia reel"

It also states Under "BEFORE TAKEOFF":


"Belts/Harness…FASTENED/ADJUSTED"

Cessna 172 Skyhawk,  N6238D:   Fatal accident  occurred March 26, 2016 at Yeager Airport (KCRW), Charleston,  Kanawha County,  West Virginia


Brenda Jackson, Flight Instructor 

Arrin Farrar, Student Pilot


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

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Charleston, West Virginia
Lycoming Engines; Milliken, Colorado
Textron Aviation; Wichita, Kansas


http://registry.faa.gov/N6238D



Location: Charleston, WV
Accident Number: ERA16FA141
Date & Time: 03/26/2016, 1208 EDT
Registration: N6238D
Aircraft: CESSNA 172N
Aircraft Damage: Substantial
Defining Event: Loss of control in flight
Injuries: 1 Fatal, 1 Serious
Flight Conducted Under: Part 91: General Aviation - Instructional

Analysis 

The flight instructor, who was controlling the airplane, and the student pilot were conducting an instructional flight. During the takeoff the airplane lifted off about 1,000 ft down the runway, pitched nose up, and rolled left to an inverted attitude before it impacted terrain next to the runway in a nose-down attitude. The student pilot recalled that as the airplane rotated during the takeoff, he heard the flight instructor exclaim, but could not recall any subsequent events. Postaccident examination of the flight controls revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation.

Examination of the wreckage revealed witness marks along the flight instructor's seat tracks that corresponded with the seat in the nearly full-aft position. Given the flight instructor's stature, it is unlikely that this position would allow her to fully actuate the flight controls, and it is therefore unlikely she purposefully initiated the takeoff with her seat in this position. While one of the two locking pins that would have secured the seat from sliding fore and aft was found fractured, it is likely that the jockeying of the seat during the victim extraction process resulted in the fracture of the locking pin, and left the witness marks observed on the seat track. Examination of the wreckage and maintenance documents also revealed that the airplane was not equipped with a manufacturer-recommended secondary seat stop mechanisms for either of the pilot seats.

Review of operational and maintenance documents published by the airframe manufacturer showed the critical importance of ensuring that the pilot seats were secured prior to initiating a flight, and that accelerations such as those encountered during a takeoff could dislodge an unsecured seat. Had the flight instructor, who was performing the takeoff, not properly secured her seat prior to initiating the takeoff, it may have resulted in her seat sliding aft, and her inadvertent application of control inputs to the control yoke during the rotation and initial climb, consistent with steep climb, descent, and impact. The aft seat position could have also likely resulted in her inability to apply complete or sufficient control inputs to the rudder pedals, consistent with the left yaw/roll observed during the takeoff.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The flight instructor's failure to ensure that her seat was properly secured before initiating the takeoff, which resulted in a subsequent loss of control. Contributing was the lack of an installed secondary seat stop. 



Findings

Aircraft
Seat/cargo attach fitting - Incorrect use/operation (Cause)

Personnel issues
Aircraft control - Instructor/check pilot (Cause)

Factual Information

History of Flight

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

Uncontrolled descent

Collision with terr/obj (non-CFIT)

HISTORY OF FLIGHT

On March 26, 2016, about 1208 eastern daylight time, a Cessna 172N, N6238D, impacted terrain during an attempted takeoff at Yeager Airport (CRW), Charleston, West Virginia. The flight instructor was fatally injured, and the student pilot was seriously injured. The airplane was registered to Skylane Aviation LLC and the flight was being conducted as a 14 Code of Federal Regulations Part 91 instructional flight. Visual meteorological conditions existed at the airport about the time of the accident, and no flight plan had been filed for the local flight. 

The student pilot stated that the flight instructor let him taxi the airplane out from the fixed-base operator. The student was having difficulty with the brakes, so the instructor took over the controls and taxied the rest of the way to the runway and run-up area. 

The student pilot stated that he did not remember much after that. However, he did remember that air traffic control told them to expedite the takeoff because another aircraft was coming in for a landing and that the flight instructor then taxied out for takeoff. He recalled that as the airplane rotated during the takeoff, he heard the flight instructor exclaim, but could not recall any subsequent events. 

Review of airport security surveillance video revealed that the airplane lifted off about 1,000 ft down runway 5, pitched up, rolled left, and then became inverted before it impacted terrain next to the runway in a nose-down attitude.

Brenda Jackson died March 26, 2016 when the Cessna 172N she was in crashed on takeoff at Yeager Airport. Jackson, who grew up flying, had been a flight instructor at Yeager Airport for the four years. 

PERSONNEL INFORMATION

Flight Instructor


According to Federal Aviation Administration (FAA) records, the flight instructor held a commercial pilot certificate with airplane single-engine land, airplane multiengine land, and instrument airplane ratings. She also held a flight instructor certificate with airplane single-engine and instrument airplane ratings. She was issued an FAA second-class medical certificate on June 11, 2015. At the time of the medical examination, the flight instructor reported 1,694 total hours of flight experience. The flight instructor's personal flight logs were not located.

Student pilot Arrin Farrar suffered serious injuries, including broken legs and hands, torn tendons, and facial fractures.


Student Pilot

The student pilot held a student pilot/FAA third-class medical certificate, issued on March 9, 2016. The student's logbook had two entries indicating 3 total hours of flight experience.



AIRCRAFT INFORMATION


The four-seat, high-wing, tricycle landing gear-equipped airplane was manufactured in 1979. It was powered by a 160-horsepower Lycoming O-320-H2AD engine and was equipped with a two-bladed McCauley propeller. Review of maintenance records revealed that the airplane's most recent annual inspection was completed on October 20, 2015. At that time, the airframe had accumulated 10,995.9 total hours of operation, and the engine had accumulated 1540.4 hours since major overhaul. The airplane had been operated about 7 hours since the last annual inspection was completed.

Examination of the airframe logbooks revealed that the seat tracks were replaced on February 12, 2015. Airworthiness Directive (AD) 2011-10-09 was accomplished about 8 months later during the most recent annual inspection. The AD required the inspection of the seat tracks, including but not limited to, the visual inspection of the holes in each track for excessive wear, the seat tracks for dirt or debris, and the seat locking pin for limited vertical play.

The pilot and copilot seats were mounted onto a set of seat tracks, which allowed the seats to slide fore and aft. An adjustment bar was used to raise and lower two locking pins into one of twelve positions along each of the seat tracks, which would secure the seat to the desired position. The locking pins downward travel and positive locking action was aided via a spring mechanism that tensioned the adjustment bar (see figure 1).

Figure 1. Illustrated Parts Catalog, Seat Diagram.

WRECKAGE AND IMPACT INFORMATION


The wreckage was contained in a small area, and ground scars were consistent with the airplane impacting in a nose-low, right-wing-down attitude. The airplane impacted the ground about 20 yards left and midfield of runway 5 and came to rest inverted. The engine and propeller were forced up and into the instrument panel and cockpit area. The leading edges of both wings were crushed due to impact forces. The fuselage had one wrinkle in the skin behind the rear window. The rudder and elevator were intact and unremarkable. The flaps and aileron were intact and unremarkable. Control cable continuity was established to all flight controls. Measurement of the elevator trim jackscrew corresponded to an approximate neutral trim setting. When the engine crankshaft was rotated by hand, valve train continuity was established, and thumb compression was attained on all cylinders. The propeller exhibited rotational scoring, and one blade tip was missing.

All four roller housing tangs (feet) on the flight instructor's seat were spread and bent. The seat tracks were gouged where they were in contact with the locking pins. One locking pin was fractured off at the roll pin. There were lockpin contact marks in the eleventh hole location from the front to back of the inboard seat rail, consistent with the seat being near the full-aft position at impact.

The inboard seat-position locking pin and outboard seat-post from the flight instructor's seat were sent to the National Transportation Safety Board's Materials Laboratory for examination. The inboard seat position locking pin had fractured, and the overall deformation pattern adjacent to the fracture was consistent with bending deformation where the outboard side of the locking pin was in tension and the inboard side was in compression. The stop-pin hole below the fracture surface on the outboard side of the rod showed necking deformation, whereas the upper side of the hole remained close to its original diameter, consistent with the stop pin being in the upper side of the hole as the locking pin was bent. Contact marks were observed on the lower side of the stop-pin hole at the inboard end of the hole, consistent with contact along the roll pin split line on the compression side of the bending fracture.



MEDICAL AND PATHOLOGICAL INFORMATION


The Office of the Chief Medical Examiner, Charleston, West Virginia, performed an autopsy on the flight instructor. The cause of death was reported to be "multiple injuries." The report also noted that the flight instructor's height was 69 inches.

The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, conducted toxicology testing on specimens from the pilot. The results were negative for carbon monoxide and drugs.




ADDITIONAL INFORMATION

The airplane's Pilot's Information Manual, before starting engine checklist, advised pilots to verify the seats, seat belts and shoulder harnesses are adjusted and locked. 

The Cessna Pilot Safety and Warnings Supplements document warned that a pilot should perform a visual check to verify that their seat was securely on the seat tracks and assure that the seat was locked in position. Failure to ensure that the seat was locked in position could result in the seat sliding aft during a critical phase of flight, such as initial climb. The airframe manufacturer also issued a Service Bulletin (SEB07-R06 Revision 6, issued June 11, 2015), which required the installation of a secondary seat stop for the pilot seat, and recommended one for the co-pilot seat. A secondary seat stop was not installed on either of the accident airplane's front pilot seats. The supplement also warned that there had been previous reported events involving seats slipping rearward or forward during acceleration or deceleration related to discrepancies in the seat mechanisms. The investigations following these events revealed discrepancies such as gouged lockpin holes, bent lockpins, excessive clearance between seat rollers and tracks, and missing seat stops. Also, dust, dirt, and debris accumulations on the seat tracks and in the intermediate adjustment hoes have been found to contribute to the problem.

Schweizer 269C-1,N204HF: Fatal accident occurred September 08, 2017 at Flying W Airport (N14), Medford, Burlington County, New Jersey


James Evan Robinson

Troy Gentry, one half of the country duo Montgomery Gentry, died after the helicopter crashed on September 8th, 2017. He was scheduled to perform at the Flying W Airport (N14) and resort later that evening. 

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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Philadelphia, Pennsylvania
Sikorsky; Coatesville, Pennsylvania
Lycoming; 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



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


http://registry.faa.gov/N204HF



Location: Medford, NJ
Accident Number: ERA17FA317
Date & Time: 09/08/2017, 1300 EDT
Registration: N204HF
Aircraft: SCHWEIZER 269C
Aircraft Damage: Substantial
Defining Event: Hard landing
Injuries: 2 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

Analysis

The purpose of the flight was to provide an orientation/pleasure flight to the passenger, who was scheduled to perform in a concert on the airport later that evening. Several minutes after takeoff, the pilot reported over the airport UNICOM frequency that he was unable to control engine rpm with throttle inputs. He reported that he could "roll" the twist-grip; however, there was no corresponding change in engine power when he did so.

Three helicopter flight instructors, one a Federal Aviation Administration (FAA) inspector, one an FAA designated examiner, and a company flight instructor, joined the conversation on the radio to discuss with the pilot remedial actions and landing options. These options included a shallow, power-on approach to a run-on landing, or a power-off, autorotational descent to landing. The instructors encouraged the pilot to perform the run-on landing, but the pilot reported that a previous run-on landing attempt was unsuccessful. He then announced that he would shut down the engine and perform an autorotation, which he said was a familiar procedure that he had performed numerous times in the past. The instructors stressed to the pilot multiple times that he should delay the engine shutdown and autorotation entry until the helicopter was over the runway surface.

Video footage from a vantage point nearly abeam the approach end of the runway showed the helicopter about 1/4 to 1/2 mile south of the runway as it entered a descent profile consistent with an autorotation. Toward the end of the video, the descent profile steepened and the rate of descent increased before the helicopter descended out of view. Witnesses reported seeing individual rotor blades as the main rotor turned during the latter portion of the descent.

The increased angle and rate of descent and slowing of the rotor blades is consistent with a loss of rotor rpm during the autorotation. Despite multiple suggestions from other helicopter instructors that he initiate the autorotation above the runway, the pilot shut down the engine and entered the autorotation from an altitude about 950 ft above ground level between 1/4 and 1/2 mile from the end of the runway. Upon realizing that the helicopter would not reach the runway, the pilot could have landed straight ahead and touched down prior to the runway or performed a 180° turn to a field directly behind the helicopter; however, he continued the approach to the runway and attempted to extend the helicopter's glide by increasing collective pitch, an action that resulted in a decay of rotor rpm and an uncontrolled descent.

Examination of the wreckage revealed evidence consistent with the two-piece throttle control tie rod assembly having disconnected in flight. The internally threaded rod attached to the bellcrank and an externally threaded rod-end bearing attached to the throttle control arm displayed damage to the three end-threads of each. The damage was consistent with an incorrectly adjusted throttle control tie rod assembly with reduced thread engagement, which led to separation of the rod end bearing from the tie rod and resulted in loss of control of engine rpm via the throttle twist grip control. 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's early entry into and failure to maintain rotor rpm during a forced landing autorotation after performing an engine shutdown in flight, which resulted in an uncontrolled descent. Contributing to the accident was the failure of maintenance personnel to properly rig the throttle control tie-rod assembly, which resulted in an in-flight separation of the assembly and rendered control of engine rpm impossible. 

Findings

Aircraft
Main rotor blade system - Incorrect use/operation (Cause)
Descent/approach/glide path - Not attained/maintained (Cause)
Descent rate - Not attained/maintained (Cause)
Power lever - Failure (Factor)

Personnel issues
Aircraft control - Pilot (Cause)
Decision making/judgment - Pilot (Cause)
Scheduled/routine maintenance - Maintenance personnel (Factor)



Factual Information


HISTORY OF FLIGHT

On September 8, 2017, about 1300 eastern daylight time, a Schweizer 269C-1 helicopter, N204HF, was substantially damaged during a collision with terrain while performing a forced landing to runway 01 at Flying W Airport (N14), Medford, New Jersey. The commercial pilot and passenger were fatally injured. The helicopter was owned by Herlihy Helicopters Inc and operated by Helicopter Flight Services under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the personal flight.

According to the chief flight instructor for the operator, the purpose of the flight was to provide an orientation/pleasure flight to the passenger, who was scheduled to perform in a concert on the airport later that evening.

Several minutes after takeoff, the pilot reported over the airport UNICOM frequency that he was unable to control engine rpm with throttle inputs. He reported that he could "roll" the twist-grip but that there was no corresponding change in engine rpm when he did so.

The company flight instructor and another helicopter flight instructor, who was a designated pilot examiner (DPE), were monitoring the frequency and engaged the pilot in conversation about potential courses of action to accomplish a landing. A Federal Aviation Administration (FAA) inspector, who was also a helicopter instructor and examiner, joined the conversation on the radio.

Options discussed included a shallow approach to a run-on landing or a power-off, autorotational descent to landing. The instructors suggested that the pilot perform the run-on landing; however, the pilot reported that a previous attempt to perform a run-on landing was unsuccessful and announced that he would stop the engine and perform a power-off autorotation. The pilot stated that this was a familiar procedure he had performed numerous times in the past. When asked over the radio by the DPE when he had last performed an autorotation to touchdown, the pilot replied that 4 months had elapsed since his most recent touchdown autorotation. Subsequent attempts to convince the pilot to attempt a run-on landing were unsuccessful.

According to the DPE and the FAA inspector, the pilot was advised "multiple times" to aim to touch down "midfield" and not to initiate the engine shutdown and autorotation until over the runway. According to the DPE, his last reminder to the pilot came when the helicopter was on a 2-mile final approach.

A video forwarded to the NTSB by local police was recorded from a vantage point nearly abeam the approach end of runway 01. The video showed the helicopter about 1/4 mile south of the runway as it entered a descent profile consistent with an autorotation. Toward the end of the video, the descent profile became more vertical, and the rate of descent increased before the helicopter descended out of view. No sound could be heard from the helicopter.

During a postaccident interview with law enforcement, the company flight instructor reported that the helicopter entered the autorotation about 950 ft above ground level (agl) and that the helicopter was quiet during its descent "because the engine was off." During the descent, the rotor rpm decayed to the point where the instructor could see the individual rotor blades. The helicopter descended from view before reaching the runway threshold, and the sounds of impact were heard. Both the instructor and the FAA inspector reported that a high-pitched "whine" could be heard from the helicopter during the latter portion of the descent.

In a written statement, the flight instructor reported, "[the pilot] began the autorotative descent, but it was not long before it became apparent it was not being executed correctly. I began to see individual blades instead of a translucent disc. His vertical speed increased while his horizontal speed became almost non-existent. The nose of the [helicopter] rolled forward. Instead of being able to see the bottom of the [helicopter]… all I could see was the cockpit glass and rotor head."

James Evan Robinson graduated from Middle Georgia State University with a Bachelor of Science degree in Aviation Science and Management. He was a commercial pilot and flight instructor having worked for Helicopter Flight Services in Medford, New Jersey.   

PERSONNEL INFORMATION

The pilot held commercial and flight instructor certificates, each with ratings for rotorcraft-helicopter and instrument helicopter. His most recent FAA second-class medical certificate was issued April 12, 2017.

Excerpts of the pilot's logbook revealed that he had logged 480.9 total hours of flight experience, of which about 300 hours were in the accident helicopter make and model. The last entry logged was for 1.2 hours in the accident helicopter on the day of the accident.

Company training records indicated that the pilot had received the training required by the operator for employment as a flight instructor, and his last airman competency check was completed satisfactorily on April 19, 2017, in the accident helicopter.

AIRCRAFT INFORMATION

The helicopter was a single-engine, two-seat, light utility helicopter constructed primarily of aluminum alloy and powered by an air-cooled, Lycoming HO-360-C1A, 180-horsepower engine. It was equipped with conventional collective and cyclic control sticks and tail rotor control pedals.

The main rotor was a fully articulated, three-bladed design, and the tail rotor was a two-bladed, semi-rigid, anti-torque rotor design. Power was transmitted from the engine to the rotor system through a V-belt drive, which incorporated a free-wheeling (one-way) sprag clutch, a main drive transmission, a tail rotor transmission, and shafts.

According to FAA records, the helicopter was manufactured in 2000, delivered to the owner/operator, and had accrued about 7,899 total aircraft hours. Its most recent 100-hour inspection was completed on August 17, 2017, at 7,884 total aircraft hours.

A review of maintenance records revealed that the helicopter's engine was replaced with factory rebuilt or overhauled engines at the manufacturer's recommended overhaul intervals. Engine changes occurred in 2003, 2006, and most recently, on September 24, 2011.

The records reflected numerous entries regarding carburetor discrepancies. Carburetors were adjusted or removed and replaced with loaner carburetors then reinstalled following repairs. In February 2014, the carburetor was removed, sent out for repair, and reinstalled by the operator.

On August 31, 2016, the operator installed a throttle control cable manufactured by McFarlane Aviation Products, as documented on an FAA Form 337. A cable from the original equipment manufacturer was not available per the operator, and the FAA approved the manufacture and installation, which required the cable's inspection at 25-hour intervals. The inspections were documented; the most recent was completed concurrent with the annual inspection conducted 15 hours before the accident.

The operator was interviewed during a meeting with NTSB investigators and FAA inspectors regarding the maintenance history of the accident helicopter. He was later interviewed by telephone to gain more detail about the disassembly/reassembly and rigging of the throttle during carburetor/engine changes.

According to the operator, when the engine was changed for overhaul, the carburetor traveled with the engine, and the throttle control arm was removed at the carburetor splined shaft. The throttle control bellcrank was removed from the front of the carburetor, and the entire throttle control system remained with the helicopter. The throttle control arm, the throttle tie rod, the throttle control bellcrank, and the throttle cable all remained attached to each other and to the helicopter. He stated that, because of this, there was no need to disconnect or adjust the throttle tie rod that connected the bellcrank and the throttle control arm.

He also stated that, when a new engine was installed, the correct "angle" was measured for the installation of the throttle control arm on the carburetor. Adjustment of idle and mixture set screws was often required, as the carburetors were often set at the factory "for airplanes."

When asked about the most recent installation of the throttle control cable, the operator stated that the cable was a fixed measurement and changing the cable did not change the rigging of the throttle. He said that, when the cable was changed, no throttle rigging adjustments were necessary; the cable was disconnected at the bellcrank upstream of the tie rod and throttle control arm. He repeated that the cable installation was "plug and play" and that no adjustments were necessary to achieve/maintain proper throttle rigging.

The operator was asked specifically about the throttle rigging and the nominal measurement of the tie rod during the throttle rigging procedure following the most recent engine change. He stated, "I don't know if I did. I'm sure I did, because that's part of the procedure, but I'm not 100 percent [sure]."

According to the manufacturer's maintenance manual, actions that required compliance with the throttle rigging procedure included:

1. Installation of a new engine (Section 3-15, page 3-26)
2. Installation of a new throttle control cable (Section 4-19, page 4-19)
3. Installation of a new carburetor (Section 5-55, page 5-21)

METEOROLOGICAL INFORMATION

At 1254, the weather recorded at South Jersey Regional Airport (VAY), 2 miles west of N14, included clear skies and wind from 260° at 13 knots gusting to 18 knots. The temperature was 21°C, and the dew point was 9°C. The altimeter setting was 30.13 inches of mercury.

AIRPORT INFORMATION

N14 was at 49 ft elevation and was equipped with a single runway, oriented 01/19. The operator's hangar was positioned at the south end of the field, approximately abeam the numbers for runway 01. A creek, oriented east/west, crossed about 200 ft south of the approach end of runway 01. The creek bed was lined with small trees and low brush and bisected the area between the runway and an open field immediately south of the airport.

The field was about 1,400 ft long and 300 ft wide at its narrowest point and was oriented in the same general direction as the runway. The surface was mowed grass or "scraped" and flattened soil.

WRECKAGE AND IMPACT INFORMATION

The wreckage was examined at the accident site and all major components of the helicopter were accounted for at the scene. The initial ground scar was about 10 ft before the main wreckage, which was about 220 ft from the threshold of runway 01 and aligned with the runway.

The cockpit was significantly deformed by impact damage, and the tailboom was separated at the fuselage. The engine and main transmission remained mounted in the airframe, and all main rotor blades were secured in their respective grips, which remained attached to the main rotor head and mast. The pitch-change link for the yellow rotor blade was fractured and displayed signatures consistent with overstress. Each of the three blades was bent significantly at its respective blade root. The blades showed little to no damage along their respective spans toward the blade tips, which was consistent with low rotor rpm at ground contact.

Flight control continuity was established from the individual flight controls through breaks to the main rotor head and tail rotor. The pilot's and co-pilot's throttles both moved together when the pilot's throttle was actuated by hand. The movement was limited due to damage on the pilot's collective; during the continuity check, an internal component of the pilot's collective disconnected and continuity between the two throttles was lost.

Continuity of the throttle control cable was confirmed from the collective jackshaft to the throttle bellcrank assembly, to which it remained securely attached. The throttle bellcrank assembly was intact, but separated from its mount, which was fractured. The internally threaded portion of the two-piece throttle control tie rod was securely attached to the throttle bellcrank assembly. The internally threaded portion of the tie rod was filled with an organic material that resembled the roots in the impact crater.

Drivetrain continuity was established to the main and tail rotors. The main gearbox housing was intact and attached to the bottom of the main rotor mast and to the center frame. The main gearbox rotated freely and exhibited continuity from input to the main rotor driveshaft, and the free-wheeling (one-way) sprag clutch operated correctly.

The engine was rotated by hand at the cooling fan, and continuity was confirmed from the powertrain through the valvetrain to the accessory section. Compression was confirmed on all cylinders using the thumb method. The magnetos were removed and actuated with a drill, and spark was produced at all terminal leads. Borescope examination of each cylinder revealed signatures consistent with normal wear, with no anomalies noted.

The carburetor was separated from the engine, displayed impact damage, and was found near the initial ground scar. The externally-threaded portion of the two-piece throttle control tie rod was still attached to the throttle arm. The throttle and mixture arms were actuated by hand and moved smoothly through their respective ranges. The filter screen was removed and was absent of debris. The carburetor contained fuel, which appeared absent of water and debris.

The collective control and jackshaft assembly with the associated throttle cable and bellcrank assemblies, as well as each half of the throttle tie rod, were retained for further examination at the NTSB Materials Laboratory.

MEDICAL AND PATHOLOGICAL INFORMATION

The Office of Medical Examiner, County of Burlington, New Jersey, performed an autopsy on the pilot. The cause of death was listed as "multiple injuries."

The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing on the pilot. The results were negative for the presence of drugs and alcohol.

TESTS AND RESEARCH

The throttle tie rod assembly was received separated at the threaded joint. The components were unbolted from the carburetor throttle arm and the throttle cable before receipt in the materials laboratory. The tie rod assembly consisted of an internally threaded rod attached to the bellcrank and an externally threaded rod-end bearing and jam nut attached to the throttle arm. The tie rod was separated at the threaded joint between the two pieces. The rod end jam nut was found about midway between the threaded end and the rod end bearing eye.

Magnified examinations of the externally threaded rod-end bearing threads revealed mechanical damage to the three end threads. The damage was consistent with thread-to-thread wear.

Visual examination of the internal threads in the rod revealed cellulose material (wood) imbedded into the threads. After brush cleaning, damage was visible to the three end threads. The damage included pock-marks and a reduced thread flank size, consistent with vibratory thread-to-thread wear. These three threads corresponded to the three worn threads on the bearing fitting. Threads further inside the rod were bright, shiny, and undamaged.

Once installed, each end of the throttle tie rod remained fixed and were unable to rotate.

An exemplar Schweizer 269C-1 helicopter was examined in Lancaster, Pennsylvania. The rigging of the throttle control arm and throttle tie rod (4.97 inches +/- .02 inch) was confirmed, and the helicopter was started and idled at a speed about 1,000 rpm. The engine was stopped, the throttle tie rod was disconnected and adjusted to the approximate operating length of the accident tie rod (5.5 inches) and reinstalled. The engine was started and idled at a speed about 1,100 rpm.

According to the Sikorsky maintenance manual for the Schweizer 269C-1 helicopter, after rigging the throttle control system, idle speed was adjusted to its prescribed rpm range (+/-200rpm) by idle/mixture screw adjustments of the carburetor.

The Sikorsky maintenance manual also required a 50-hour inspection of the engine in accordance with the engine manufacturer's publications and a 100-hour inspection of the fuel control linkage. The Sikorsky flight manual required an inspection of the general engine area before each flight.

On November 16, 2017, Sikorsky Aircraft Corporation issued Alert Service Bulletin ASB-C1B-048 for a one-time inspection of the throttle control tie rod assembly to verify the length of throttle control tie rod assembly dimension.

ORGANIZATIONAL AND MANAGEMENT INFORMATION

The owner of Helicopter Flight Services held airline transport, commercial, and flight instructor certificates with multiple ratings for each. He also held a mechanic certificate with ratings for airframe, powerplant, and inspection authorization, and performed much of the maintenance of the accident helicopter, including the most recent throttle cable inspection.

ADDITIONAL INFORMATION

US Army Hughes TH-55A (Hughes/Schweizer 269) Manual (TM 55-1520-233-10) Chapter 9, Emergency Procedures, 9-12, Throttle Failure, stated, "If the throttle becomes inoperative in flight, continue to a landing area that will permit a shallow approach and running landing."

The manufacturer's Pilot's Flight Manual does did not contain an emergency procedure for throttle failure. An informal survey of two other manufacturers of piston-powered helicopters by the FAA inspector assigned to this accident revealed that neither published such a procedure in their flight manuals.

The US Army Training Circular (TC) 3-04.4, "Fundamentals of Flight," specified the following regarding autorotations:

1-123. During powered flight, rotor drag is overcome with engine power. When the engine fails or is deliberately disengaged from the rotor system, some other force must sustain rotor RPM so controlled flight can be continued to the ground. Adjusting the collective pitch to allow a controlled descent generates this force. Airflow during helicopter descent provides energy to overcome blade drag and turn the rotor. When the helicopter descends in this manner, it is in a state of autorotation. In effect, the aviator exchanges altitude at a controlled rate in return for energy to turn the rotor at a RPM [an rpm] that provides aircraft control and a safe landing. Helicopters have potential energy based on their altitude above the ground. As this altitude decreases, potential energy is converted into kinetic energy used in turning the rotor. Aviators use this kinetic energy to slow the rate of descent to a controlled rate and affect a smooth touchdown.

Circle of Action

1-139. The circle of action is a point on the ground that has no apparent movement in the pilot's field of view (FOV) during a steady-state autorotation. The circle of action would be the point of impact if the pilot applied no deceleration, initial pitch, or cushioning pitch during the last 100 feet of autorotation. Depending on the amount of wind present and the rate and amount of deceleration and collective application, the circle of action is usually two or three helicopter lengths short of the touchdown point.

Last 50 to 100 Feet

1-140. It can be assumed autorotation ends at 50 to 100 feet and landing procedures then begin. To execute a power-off landing for rotary-wing aircraft, an aviator exchanges airspeed for lift by decelerating the aircraft during the last 100 feet. When executed correctly, deceleration is applied and timed so rate of descent and forward airspeed are minimized just before touchdown. At about 10 to 15 feet, this energy exchange is essentially complete. Initial pitch application occurs at 10 to 15 feet. This is used to trade some of the rotor energy to slow the rate of descent prior to cushioning. The primary remaining control input is application of collective pitch to cushion touchdown. Because all helicopter types are slightly different, aviator experience in that particular aircraft is the most useful tool for predicting useful energy exchange available at 100 feet and the appropriate amount of deceleration and collective pitch needed to execute the exchange safely and land successfully.

FAA Advisory Circular (AC) 61-140, "Autorotation Training - Predominant Cause of Accidents/Incidents," states:

A review of NTSB reportable accidents and incidents during autorotation training/instruction indicates that the predominant probable cause is failure to maintain main rotor .... rpm (Nr) and airspeed within the Rotorcraft Flight Manual (RFM) or pilot's operating handbook (POH) specified range, resulting in an excessive and unrecoverable rate of descent."

According to the FAA Helicopter Handbook: "If too much collective pitch is applied too early during the final stages of the autorotation, the kinetic energy may be depleted, resulting in little or no cushioning effect available. This could result in a hard landing with corresponding damage to the helicopter."

The US Army Hughes TH-55A Manual (TM 55-1520-233-10) states in Chapter 9, Emergency Procedures, 9-12, Engine Failure – Cruise, "Collective pitch should never be applied to reduce rpm for extending glide distance because of the reduction in rpm available for use during touchdown. 

History of Flight

Maneuvering
Powerplant sys/comp malf/fail

Autorotation
Hard landing (Defining event)

Pilot Information

Certificate: Flight Instructor; Commercial
Age: 30, Male
Airplane Rating(s): None
Seat Occupied: Right
Other Aircraft Rating(s): Helicopter
Restraint Used: 4-point
Instrument Rating(s): Helicopter
Second Pilot Present: No
Instructor Rating(s): Helicopter; Instrument Helicopter
Toxicology Performed: Yes
Medical Certification: Class 2 Without Waivers/Limitations
Last FAA Medical Exam: 04/12/2017
Occupational Pilot: Yes
Last Flight Review or Equivalent: 04/19/2017
Flight Time: 480 hours (Total, all aircraft), 300 hours (Total, this make and model)

Aircraft and Owner/Operator Information

Aircraft Make: SCHWEIZER
Registration: N204HF
Model/Series: 269C 1
Aircraft Category: Helicopter
Year of Manufacture: 2000
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 0109
Landing Gear Type: Skid
Seats: 2
Date/Type of Last Inspection: 08/17/2017, 100 Hour
Certified Max Gross Wt.: 1750 lbs
Time Since Last Inspection: 15 Hours
Engines: 1 Reciprocating
Airframe Total Time: 7899.2 Hours at time of accident
Engine Manufacturer: Lycoming
ELT: Not installed
Engine Model/Series: HIO-360-C1A
Registered Owner: HERLIHY HELICOPTERS INC
Rated Power: 180 hp
Operator: Helicopter Flight Services
Operating Certificate(s) Held:  Pilot School (141)

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KVAY, 53 ft msl
Distance from Accident Site: 2 Nautical Miles
Observation Time: 1254 EDT
Direction from Accident Site: 299°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 13 knots / 18 knots
Turbulence Type Forecast/Actual: / None
Wind Direction: 260°
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 30.13 inches Hg
Temperature/Dew Point: 21°C / 9°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Medford, NJ (N14)
Type of Flight Plan Filed: None
Destination: Medford, NJ (N14)
Type of Clearance: None
Departure Time: 1245 EDT
Type of Airspace: Class G

Airport Information

Airport: FLYING W (N14)
Runway Surface Type: Asphalt
Airport Elevation: 49 ft
Runway Surface Condition: Dry; Vegetation
Runway Used: 01
IFR Approach: None
Runway Length/Width: 3496 ft / 75 ft
VFR Approach/Landing:  Forced Landing; Precautionary Landing

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries: 1 Fatal
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Fatal
Latitude, Longitude: 39.934167, -74.807222 (est)

Location: Medford, NJ
Accident Number: ERA17FA317
Date & Time: 09/08/2017, 1300 EDT
Registration: N204HF
Aircraft: SCHWEIZER 269C
Injuries: 2 Fatal
Flight Conducted Under:  Part 91: General Aviation - Personal 

On September 8, 2017, about 1300 eastern daylight time, a Schweizer 269C-1 helicopter, N204HF, operated by Helicopter Flight Services, was substantially damaged during collision with terrain while performing a forced landing to Runway 01 at Flying W Airport (N14), Medford, New Jersey. The commercial pilot and passenger were fatally injured. Visual meteorological conditions prevailed, and no flight plan was filed for the personal flight which was conducted under the provisions of 14 Code of Federal Regulations Part 91.

According to the chief flight instructor for the operator, the purpose of the flight was to provide an orientation/pleasure flight to the passenger who was scheduled to perform in a concert on the airport later that evening.

Several minutes after takeoff, the pilot reported over the airport UNICOM frequency that he was unable to control engine rpm with throttle inputs. He reported he could "roll" the twist-grip, but that there was no corresponding change in engine rpm when he did so.

The company flight instructor and another certificated helicopter flight instructor were monitoring the frequency and engaged the pilot in conversation about potential courses of action to affect the subsequent landing. Options discussed included a shallow approach to a run-on landing, or a power-off, autorotational descent to landing. The pilot elected to stop the engine and perform an autorotation, which was a familiar procedure he had performed numerous times in the past. Prior to entering the autorotation, the pilot was advised to initiate the maneuver over the runway.

The company flight instructor reported that the helicopter entered the autorotation about 950 ft above ground level, and that the helicopter was quiet during its descent "because the engine was off." During the descent, the rotor rpm decayed to the point where the instructor could see the individual rotor blades. The helicopter descended from view prior to reaching the runway threshold and the sounds of impact were heard. Both instructors reported that a high-pitched "whine" could be heard from the helicopter during the latter portion of the descent.

A video forwarded by local police showed the helicopter south of the runway as it entered what appeared to be a descent profile consistent with an autorotation. Toward the end of the video, the descent profile became more vertical and the rate of descent increased before the helicopter descended out of view. No sound could be heard from the helicopter.

The pilot held commercial and instructor pilot certificates, each with ratings for rotorcraft-helicopter and instrument helicopter. His most recent Federal Aviation Administration (FAA) second-class medical certificate was issued April 12, 2017.

Excerpts of the pilot's logbook revealed he had logged 480.9 total hours of flight experience. It was estimated that he had accrued over 300 total hours of flight experience in the accident helicopter make and model. The last entry logged was for 1.2 hours in the accident helicopter on the day of the accident.

The company training records indicated the pilot had received the training required by the operator for employment as a flight instructor, and his last airman competency check was completed satisfactorily on April 19, 2017 in the accident helicopter.

According to FAA records, the helicopter was manufactured in 2000 and had accrued approximately 7,900 total aircraft hours. Its most recent 100-hour inspection was completed August 17, 2017 at 7,884 total aircraft hours.

At 1254, the weather recorded at South Jersey Regional Airport (VAY), 2 miles west of N14, included clear skies and wind from 260° at 13 knots gusting to 18 knots. The temperature was 21°C, and the dew point was 9°C. The altimeter setting was 30.13 inches of mercury.

The wreckage was examined at the accident site, and all major components were accounted for at the scene. The initial ground scar was about 10 ft prior to the main wreckage, which was about 220 ft prior to the threshold of runway 01 and aligned with the runway.

The cockpit was significantly deformed by impact damage, and the tailboom was separated at the fuselage. The engine and main transmission remained mounted in the airframe, and all main rotor blades were secured in their respective grips, which remained attached to the main rotor head and mast. The pitch-change link for the yellow rotor blade was fractured, with fracture signatures consistent with overstress. Each of the three blades was bent significantly at its respective blade root. The blades showed little to no damage along their respective spans toward the blade tips, which was consistent with low rotor rpm at ground contact.

Flight control continuity was established from the individual flight controls, through breaks, to the main rotor head and tail rotor. Drivetrain continuity was also established to the main and tail rotors.

The engine was rotated by hand at the cooling fan, and continuity was confirmed from the powertrain through the valvetrain, to the accessory section. Compression was confirmed on all cylinders using the thumb method. The magnetos were removed, actuated with a drill, and spark was produced at all terminal leads. Borescope examination of each cylinder revealed signatures consistent with normal wear, with no anomalies noted.

The carburetor was separated from the engine, displayed impact damage, and was found near the initial ground scar. The throttle and mixture arms were actuated by hand and moved smoothly through their respective ranges. The filter screen was removed, and was absent of debris. The carburetor contained fuel which appeared absent of water and debris.

The collective control and jackshaft assembly as well as the associated throttle cable, push-pull tube, and bellcrank assemblies were retained for further examination at the NTSB Materials Laboratory.

Aircraft and Owner/Operator Information

Aircraft Manufacturer: SCHWEIZER
Registration: N204HF
Model/Series: 269C 1
Aircraft Category: Helicopter
Amateur Built: No
Operator: Helicopter Flight Services
Operating Certificate(s) Held:  Pilot School (141) 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KVAY, 53 ft msl
Observation Time: 1254 EDT
Distance from Accident Site: 2 Nautical Miles
Temperature/Dew Point: 21°C / 9°C
Lowest Cloud Condition: Clear
Wind Speed/Gusts, Direction: 13 knots/ 18 knots, 260°
Lowest Ceiling: None
Visibility:  10 Miles
Altimeter Setting: 30.13 inches Hg
Type of Flight Plan Filed: None
Departure Point: Medford, NJ (N14)
Destination:  Medford, NJ (N14) 

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries: 1 Fatal
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Fatal
Latitude, Longitude:  39.934167, -74.807222 (est)

Piper PA-28-140 Cherokee Cruiser,   N32396:     Fatal accident occurred March 29, 2015 near  Orange County Airport  (KOMH), Virginia


Ryan Lee McCall


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

Additional Participating Entities: 

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

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

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

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

http://registry.faa.gov/N32396 


Location: Orange, VA
Accident Number: ERA15FA170
Date & Time: 03/29/2015, 0940 EDT
Registration: N32396
Aircraft: PIPER PA-28-140
Aircraft Damage: Substantial
Defining Event: Aerodynamic stall/spin
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Instructional

Analysis

The student pilot was departing on a solo cross-country flight. Witnesses reported that they observed the airplane taking off and that it appeared to be "abnormally slow" and did not seem to be gaining altitude. They also reported observing a trail of "smoke" or "exhaust" emanating from the engine. When the airplane was about 150 ft above ground level, its nose pitched up abruptly, the left wing dropped, and the airplane impacted terrain about 1,300 ft from the departure end of the runway. Ground scars and damage to the airplane were consistent with a near-vertical impact.

Postaccident examination of the airframe revealed no anomalies, and there was no evidence of fuel contamination. Engine powertrain and valve train continuity was established, and borescope examination of the cylinders revealed no anomalies. The spark plugs were removed, and all of them exhibited significant carbon-fouling. During testing, three of the eight plugs displayed weak and intermittent spark. Flow testing revealed that, throughout all power settings, the carburetor produced a fuel flow that was richer than the maximum acceptable limits prescribed by the manufacturer. Review of the airplane's maintenance logbooks indicated that the carburetor was last serviced about 2 years (300 flight hours)  before the accident. The condition of the spark plugs, as well as the witness accounts of smoke/exhaust, was consistent with the engine operating in an overly rich fuel/air mixture condition; however, the investigation could not determine how long the engine had been experiencing this condition.

None of the witnesses reported rough engine operation or a loss of power before the accident, and each of the witness observations was consistent with an aerodynamic stall/spin. Although the effect of the fouled spark plugs and overly rich fuel/air mixture on the engine operation could not be determined, it is possible that the engine's performance was degraded during the takeoff, which would likely have been a source of distraction for the student pilot and may have contributed to the loss of control. 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The student pilot's failure to maintain adequate airspeed after takeoff, which resulted in the airplane exceeding its critical angle-of-attack and experiencing an aerodynamic stall.

Findings

Aircraft
Angle of attack - Capability exceeded (Cause)
Fuel control/carburetor - Related operating info

Personnel issues
Aircraft control - Student pilot (Cause)



Factual Information

HISTORY OF FLIGHT

On March 29, 2015, about 0940 eastern daylight time, a Piper PA-28-140, N32396, impacted terrain during takeoff from Orange County Airport (OMH), Orange, Virginia. The airplane was substantially damaged, and the student pilot was fatally injured. Visual meteorological conditions prevailed and no flight plan was filed for the flight, which was operated by Skyline Aviation Services. The solo instructional flight was destined for Farmville Regional Airport (FVX), Farmville, Virginia, and was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.

The owner of the flight school was also a flight instructor (CFI) who had flown with the student on several occasions. She stated that the student was departing on his first solo cross-country flight when the accident occurred. The morning of the accident, she reviewed his preflight planning, endorsed his logbook for the flight, and assisted him in a preflight inspection of the airplane and engine run-up check. She stated that she observed no anomalies with the airplane. The pilot then taxied the airplane to the other side of the airport to obtain fuel, then performed a second engine run-up and departed from runway 08. She stated that the takeoff appeared normal, but the pilot initiated a left turn to the crosswind leg of the traffic pattern earlier than was customary. As the airplane turned left, its nose pitched up abruptly, and it rolled sharply left and descended to ground contact. The CFI immediately called 911 and responded to the accident site to render assistance.

Two pilot-rated witnesses located on the north side of the airport observed the airplane during the takeoff and provided written statements to local law enforcement. They remarked to each other that the airplane appeared "abnormally slow" and stated that it did not seem to be gaining altitude. Both individuals also reported viewing a thin trail of "smoke" or "brown exhaust" from the airplane's engine. The witnesses observed the airplane make a sharp left turn from an altitude about 150 feet above ground level, and descend steeply to ground contact. One of the witnesses reported that the wind at the time of the accident was light and variable from the north and east. In subsequent, separate telephone interviews, both witnesses stated that they did not observe any birds in the vicinity of the airport at the time of the accident. Additionally, neither of the witnesses perceived any changes or abnormalities in the airplane's engine noise during the takeoff, though one of the witnesses reported that the engine sounded "quieter than it should be."

Another witness reported that he was driving parallel to the runway at OMH. He reported seeing the accident airplane accelerate down the runway, and stated that it "looked like it was having trouble" shortly after it became airborne. He observed the airplane's nose pitch up twice, and also observed a trail of black smoke that extended the length of the airplane. He stated that the airplane appeared to "level out," then made a "hard" left turn as the nose dropped. The airplane then disappeared from his view behind trees and terrain.

PERSONNEL INFORMATION

The pilot held a student pilot certificate and Federal Aviation Administration (FAA) third-class medical certificate, which was issued on January 20, 2015. Review of the pilot's logbook revealed that he had accumulated 30.6 total hours of flight experience, of which about 18 hours were in the accident airplane, and 2.7 hours were solo. 

AIRPLANE INFORMATION

The airplane was manufactured in 1974, and was originally equipped with a Lycoming O-320 series, 150 hp reciprocating engine. In 2002, the engine was overhauled and equipped with a Penn Yan Aero RAM160 supplemental type certificate, which resulted in an increase to 160 hp. Review of maintenance logs indicated that the airplane's most recent 100-hour inspection was completed on February 20, 2015, at a total airframe time of 5,156 hours. At the time of the accident, the airplane had accrued 5,187.6 hours in operation.

According to the owner of the flight school, the school had operated the accident airplane under a lease agreement for about 18 months prior to the accident, and had purchased the airplane about 3 weeks prior to the accident.

METEOROLOGICAL INFORMATION

The 0935 weather observation at OMH included wind from 040 degrees at 3 knots, 10 miles visibility, clear skies, temperature 0 degrees C, dew point -12 degrees C, and an altimeter setting of 30.41 inches of mercury.

WRECKAGE AND IMPACT INFORMATION

The airplane came to rest upright in a field located about 1,330 feet northeast of the departure end of runway 08, with the wreckage oriented on a heading of about 170 degrees magnetic. The initial impact point was identified by a ground scar about 30 feet south of the main wreckage that contained pieces of the left wing navigation light. Areas of disturbed soil extended north from the initial impact point about 15 feet toward a large impact crater about 6 feet in length and 3 feet in width, which contained pieces of the propeller spinner and ground scars consistent with propeller contact.

The propeller remained attached to the crankshaft flange and one blade exhibited slight forward bending. Both blades displayed chordwise scratching and leading edge gouging. The engine remained attached to the fuselage by its bottom mounts. The fuselage displayed significant aft crushing from the engine firewall to the rear cabin seats, and was displaced to the left just aft of the baggage area.

Both left and right wings displayed significant aft crushing of their leading edges. The left wing was separated from the fuselage at its root and the fuel tank was breached. Residual fuel was found inside, and the fuel tank cap was in place and secure. The left aileron remained attached at its hinge points. Control continuity was established from the aileron to the cockpit area through cable breaks at the wing root that displayed signatures consistent with overstress failure.

The right wing remained attached to the fuselage at its root. The outboard approximate 4 feet was bent upward about 45 degrees. The right fuel tank was breached and leaking fuel; the right fuel tank cap was in place and secure. The right aileron remained attached at its hinge points and control continuity was established from the aileron to the cockpit area. The wing flaps were fully retracted.

The empennage was intact and displayed minor impact damage. The rudder remained attached to the vertical stabilizer at its hinge points, and the stabilator remained attached at its mounting blocks. Rudder and stabilator control continuity was established to the cockpit area. The stabilator trim screw indicated a trim position between neutral and full nose-up trim. The windscreen and left cabin window were destroyed upon impact, and pieces of each were distributed along the wreckage path and around the main wreckage. Examination of the wings, empennage, and windscreen pieces did not reveal any evidence of a bird strike.

The carburetor heat control was in the "off" position, and the engine primer was in and locked. The fuel selector was in the right tank position, and could not be manipulated due to impact damage.

The engine crankshaft was rotated by hand at the propeller hub and continuity of the valve and powertrains was confirmed. The spark plugs were removed and displayed black carbon fouling. The #1 and #3 cylinder bottom plugs were oil-covered; consistent with the engine's postimpact orientation. Thumb compression was obtained on all cylinders, and borescope examination of the cylinders revealed no anomalies. The carburetor inlet screen was absent of debris. The carburetor was removed and the bowl was opened. The floats were intact, and the bowl contained fuel consistent with the color and odor of 100 low lead aviation fuel and was absent of contamination. The magnetos remained secured to their mounts, and were removed and actuated by hand. Each magneto produced spark at all of its terminal leads.

The airplane was examined at a secure storage facility on April 29, 2015. The pilot's seat was secure on the track, and the seat position adjustment lever functioned properly when manipulated. Neither the seat track nor the locking pins displayed any abnormal or excessive wear. The spark plugs were tested for operation. Three of the eight plugs produced weak and intermittent spark. One plug produced no spark; however, this plug was likely damaged during postaccident removal from the engine.

The stall warning switch was removed for testing and electrical continuity was confirmed when the switch was manipulated. 

MEDICAL INFORMATION

An autopsy was performed by the Office of the Chief Medical Examiner Northern Virginia District, Manassas, Virginia. The cause of death was identified as blunt trauma. Toxicological testing was performed by the FAA Bioaeronautical Sciences Research Laboratory in Oklahoma City, Oklahoma. Testing was negative for carbon monoxide, ethanol, and all tested-for drugs and their metabolites.

ADDITIONAL INFORMATION

Carburetor Testing

The carburetor was examined and tested at the manufacturer's facility on May 26, 2015, with an FAA inspector present. Initial flow testing revealed that the main gasket and float were misaligned; likely due to the disassembly and reassembly performed on-scene. The floats appeared to be in good condition and the arms were not damaged. The floats were aligned properly, and the carburetor was flow tested a second time at four different power settings. Throughout all power settings, the carburetor produced a fuel flow that was between 9.3% and 12.1% richer than the master unit, and between 2.5% and 7.5% richer than the maximum acceptable limits prescribed by the manufacturer.

Further review of the airplane's maintenance logs revealed that the airplane did not undergo any inspections or maintenance between December 2010, at a total airframe time of 4,876.7 hours, and an annual inspection in May 2013, at a total time of 4,887.4 hours. Review of work orders indicated that in February 2013, all four engine cylinders were disassembled, cleaned, inspected, and returned to service limits. In April 2013, the carburetor was "repaired as necessary;" the work order also indicated compliance with a manufacturer service bulletin that called for the replacement of hollow floats with solid, epoxy floats.

Stall and Spin Awareness

FAA Advisory Circular 61-67C, "Stall and Spin Awareness Training," stated, "Stalls resulting from improper airspeed management are most likely to occur when the pilot is distracted by one or more tasks, such as locating a checklist or attempting a restart after an engine failure; flying a traffic pattern on a windy day; reading a chart or making fuel and/or distance calculations; or attempting to retrieve items from the floor, backseat, or glove compartment. Pilots at all skill levels should be aware of the increased risk of entering into an inadvertent stall or spin while performing tasks that are secondary to controlling the aircraft." 

History of Flight

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

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

Pilot Information

Certificate: Student
Age: 16, Male
Airplane Rating(s): None
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 Without Waivers/Limitations
Last FAA Medical Exam: 01/20/2015
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time:   30.6 hours (Total, all aircraft), 18 hours (Total, this make and model), 2.7 hours (Pilot In Command, all aircraft), 8.5 hours (Last 90 days, all aircraft), 6.7 hours (Last 30 days, all aircraft), 0 hours (Last 24 hours, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: PIPER
Registration: N32396
Model/Series: PA-28-140
Aircraft Category: Airplane
Year of Manufacture:
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 28-7525060
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection: 02/20/2015, 100 Hour
Certified Max Gross Wt.: 2150 lbs
Time Since Last Inspection: 31 Hours
Engines: 1 Reciprocating
Airframe Total Time: 5156.39 Hours as of last inspection
Engine Manufacturer: LYCOMING
ELT: C91A installed, activated, did not aid in locating accident
Engine Model/Series: O-320 SERIES
Registered Owner: Grace Flight LLC
Rated Power: 160 hp
Operator: Skyline Aviation Services
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KOMH, 469 ft msl
Distance from Accident Site: 0 Nautical Miles
Observation Time: 0935 EDT
Direction from Accident Site: 238°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 3 knots /
Turbulence Type Forecast/Actual: / None
Wind Direction: 40°
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 30.41 inches Hg
Temperature/Dew Point: 0°C / -12°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Orange, VA (OMH)
Type of Flight Plan Filed: None
Destination: Farmville, VA (FVX)
Type of Clearance: None
Departure Time: 0940 EDT
Type of Airspace: Class E

Airport Information

Airport: Orange County Airport (OMH)
Runway Surface Type: Asphalt
Airport Elevation: 464 ft
Runway Surface Condition: Dry
Runway Used: 08
IFR Approach: None
Runway Length/Width: 3200 ft / 75 ft
VFR Approach/Landing: None

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:  38.251389, -78.037222

Cessna T310R, N72TP: Fatal accident occurred July 18, 2015 in Cody, Park County, Wyoming


 Donald Edward Scott

Joyce Louise Bartoo 


Gerald and Diane Stubbs


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

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Casper, Wyoming
Textron Aviation; Wichita, Kansas
Continental Motors; Mobile, Alabama 

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

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

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

http://registry.faa.gov/N72TP




Location: Cody, WY
Accident Number: CEN15FA307
Date & Time: 07/18/2015, 1155 MDT
Registration: N72TP
Aircraft: CESSNA T310R
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight
Injuries: 4 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal

Analysis

After flying over Yellowstone National Park at 13,500 ft, the pilot requested an instrument flight rules (IFR) clearance direct to Billings Logan International Airport (BIL), Billings, Montana. At that time, the airplane was at 13,300 ft and was below the minimum en route altitude of 14,400 ft. After confirming that the pilot could maintain terrain and obstacle clearance, the controller issued an IFR clearance direct to BIL (to the north-northeast) and instructed the pilot to climb to and maintain 15,000 ft. An AIRMET was in effect for icing between 14,000 ft and FL (flight level) 220 in the area; the controller did not provide this information to the pilot, and it could not be determined if the pilot was aware of the AIRMET. After the airplane reached 15,000 ft, the controller made a radar handoff and attempted to transfer radio communications, but the pilot did not respond. The controller stated that the airplane turned east and began a rapid descent. The airplane impacted a creek bed in heavily wooded mountainous terrain at an elevation of 7,762 ft. Tree heights were about 100 ft. There was a scrape mark on the side of one tree, and another tree had the top broken off. No other trees were damaged, consistent with the airplane having descended through the tree canopy in a near-vertical attitude. The airplane was severely fragmented and had been exposed to a postimpact fire.

The wreckage, engines, propellers and turbochargers were subsequently examined. The left propeller bore evidence of little or no rotation. Disassembly revealed it was in the “low pitch/high rpm” position. Disassembly of the left engine revealed no anomalies. The left engine turbocharger turbine bore no rotational marks and could not be rotated. No rub marks were noted on the turbine housing. It is likely that the left engine was not operating at the time of impact. The outboard end of the recovered right propeller blade bore chordwise scratches. Disassembly of the right engine revealed no anomalies. The right engine turbocharger turbine rotated freely when turned by hand. The pilot likely lost control of the airplane following the loss of left engine power. Although the airplane was operating in an area conducive to aircraft icing, the reason for the loss of engine power could not be determined during postaccident examinations.

Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's loss of airplane control following the loss of power in the left engine; the reason for the loss of power could not be determined during postaccident engine examination.

Findings

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

Personnel issues
Aircraft control - Pilot (Cause)

Not determined
Not determined - Unknown/Not determined (Cause)



Factual Information

HISTORY OF FLIGHT

On July 18, 2015, at 1154 mountain daylight time, a Cessna T310R airplane, N72TP, impacted mountainous terrain near Cody, Wyoming. The pilot and three passengers were fatally injured. The airplane was destroyed. The airplane was registered to and operated by Independence Aviation LLC, Englewood, Colorado, under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Day visual meteorological conditions (VMC) prevailed at the time, and an instrument flight rules (IFR) flight plan had been air filed. The flight originated from the Sheridan County Airport (SHR), Sheridan, Wyoming, about 1030 and was destined for the Billings Logan International Airport (BIL), Billings, Montana.

According to Independence Aviation Dispatch papers, the pilot rented the airplane on July 16, 2015, at 0900, and was scheduled to return on July 21, 2015, at 1800. The passengers included the pilot's girlfriend, his sister (both of the latter retired attorneys) and her husband. Their travel itinerary between July 16 and July 17 is unknown. The airplane arrived at SHR at some time on July 17. They departed SHR on July 18 about 1030.

Radar track data indicated that N72TP departed SHR in VMC conditions, turned to a westerly heading, and flew over Yellowstone National Park at 13,500 feet. It then turned south and then east and flew back over the Park. At 1148, the pilot contacted the Salt Lake Air Route Traffic Control Center (ARTCC-ZLC) R16 controller and requested an IFR clearance direct to BIL. At that time, the airplane was still at 13,300 feet. The R16 controller issued a beacon code and identified the airplane on radar but he did not issue a current altimeter setting or confirm its mode C altitude. N72TP was below the minimum IFR altitude of 14,400 feet. After confirming the pilot could maintain terrain and obstacle clearance, the controller issued an IFR clearance direct to BIL and instructed the pilot to climb and maintain 15,000 feet. The controller did not advise the pilot of an AIRMET (airmen meteorology) in effect in that area for icing between 14,000 feet and FL (flight level) 220 (22,000 feet).

At 1154, the R16 controller made a radar handoff after N72TP had attained 15,000 feet and attempted to transfer radio communications. There was no response. N72TP was seen to turn east and then southeast in a rapid descent and in the direction of Cody. A low altitude alert was not issued and N72TP was not advised that radar contact had been lost. The R16 controller attempted to contact N72TP several times, and asked another aircraft to attempt to contact the airplane. When radar and radio contact was lost, the airplane was on the 253° radial from the COD (COD) VORTAC (Very High Frequency Omnidirectional Radio Range) at 21 DME (Distance Measuring Equipment) miles. ZLC then contacted the Park County 911 Communications Center and issued an Alert Notice (ALNOT) 23 minutes after radar and radio contact was lost.

PERSONNEL (CREW) INFORMATION

The pilot, age 66, held a commercial pilot certificate with airplane multiengine and instrument ratings, and private pilot privileges with a airplane single-engine land rating. He also held a third class airman medical certificate, dated June 9, 2015, with no restrictions or limitations. According to his application for this medical certificate, the pilot estimated he had accrued 571 total flight hours. According to a spokesman for Independence Aviation, their records indicated the pilot had logged 162.7 hours in the Cessna 310.

AIRCRAFT INFORMATION

N72TP (serial number 310R1628), a model T310R, was manufactured by the Cessna Aircraft Company in 1979. It was equipped with two Continental TSIO-520-EB engines (serial numbers 206174-9-E, left; 244934-R, right), each rated at 300 horsepower, driving two Hartzell 3-blade, all-metal, constant speed, full-feathering Q-tip propellers (left propeller: model number FC7693DF, serial number EB030B; blade 1, K76440; blade 2, K76441; blade 3, K76443). Only the outboard portion of one blade was recovered from the right propeller assembly. Both engines were equipped with Kelly Aerospace (formerly Hartzell, Garrett Allied Signal) turbochargers.

METEOROLOGICAL INFORMATION

The following pertinent METAR (Meteorological Terminal Aviation Routine Weather Report) was recorded by the Automated Weather Observing System (ASOS-3) at Yellowstone Regional Airport (KCOD):

Wind, 010° at 5 knots; visibility, 10 miles; sky condition, clear; temperature, 16° Celsius (C.); dew point, 6° C.; altimeter, 30.19 inches of mercury.

There was an AIRMET in effect for icing between 14,000 feet and FL (flight level) 220 (22,000 feet) in the area.

WRECKAGE AND IMPACT INFORMATION

The wreckage was located 1.5 miles west of the Mooncrest Ranch, north of the Buffalo Bill Reservoir, and 4 miles east of 12,244-foot Trout Peak. The airplane had impacted a creek bed in heavily wooded mountainous terrain about 21 miles west-northwest of Cody, Wyoming, at an elevation of 7,762 feet. Tree heights were about 100 feet. There was a scrape mark on the side of one tree, and another tree had the top broken off. No other trees were damaged, consistent with the airplane having descended through the tree canopy in a near vertical attitude. The debris scatter was aligned on a magnetic heading of 230° degrees. Portions of all main components of the airplane -- including both tip tanks, portions of the main fuselage, portions of the horizontal stabilizer and elevator, the vertical stabilizer and rudder, portions of both wings, both engines, and both propellers -- were located in the immediate area of the accident.

The airplane was severely fragmented and had been exposed to a post-impact fire. Trees in the immediate vicinity were also fire damaged. Due to the extensive fragmentation of the airplane, photo documentation of the wreckage was made. The wreckage was then recovered and transported to Beegles Aircraft Service, in Greeley, Colorado, for further examination.

MEDICAL AND PATHOLOGICAL INFORMATION

Autopsies were performed on the pilot and the three passengers by Forensic Medicine and Pathology, Billings, Montana. According to the pilot's autopsy report, death was attributed to multiple blunt force traumas. The pilot's toxicology report revealed no ethanol in the liver and muscle tissue. Ibuprofen and solifenacin were detected in the liver (solifenacin is used in the treatment of contraction of an overactive bladder with associated problems such as increased urination frequency and urge incontinence). Carbon monoxide and cyanide tests were not performed.

TESTS AND RESEARCH

On December 7 and 8, 2015, the engines, propellers, and turbochargers were disassembled and examined at Continental Motors, Mobile, Alabama.

The left propeller bore evidence of little or no rotation. Disassembly revealed it was in the LOW PITCH/HIGH RPM position. Disassembly of the left engine revealed no anomalies. The engine-driven fuel pump vanes were intact, but could only be partially when rotated by hand. There was no evidence of oil starvation. The rod bearings appeared normal. The turbocharger turbine bore no rotational marks. The turbine and compressor could not be rotated. No rub marks were noted on the turbine housing. The compressor bore impact crush damage. The wastegate operated normally.

The outboard end of the recovered right propeller blade bore chordwise scratches. Disassembly of the right engine revealed no anomalies. The engine-driven fuel coupling was sheared. The coupling was taken to Continental's metallurgical laboratory for analysis. According to their report, "the fractured surfaces showed evidence of mechanical overload" and "did not exhibit signs of extended contact or rotation after separation." The turbocharger turbine rotated freely when turned by hand. There was some metal splatter noted on the turbine housing. The compressor bore impact crush damage and could not be rotated. The wastegate operated normally.

ADDITIONAL INFORMATION

The wreckage was released to the insurance adjuster on January 29, 2016.

In addition to the Federal Aviation Administration, parties to the investigation include Textron Aviation (formerly Cessna), Continental Motors, Hartzell Propeller, and RAM Aircraft.

History of Flight

Enroute-climb to cruise
Loss of engine power (total)
Loss of control in flight (Defining event)

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

Pilot Information

Certificate: Commercial
Age: 66
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 Without Waivers/Limitations
Last FAA Medical Exam: 06/09/2015
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time:  571 hours (Total, all aircraft), 163 hours (Total, this make and model)

Aircraft and Owner/Operator Information

Aircraft Make: CESSNA
Registration: N72TP
Model/Series: T310R R
Aircraft Category: Airplane
Year of Manufacture:
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 310R1628
Landing Gear Type: Retractable - Tricycle
Seats: 6
Date/Type of Last Inspection:
Certified Max Gross Wt.:
Time Since Last Inspection:
Engines:
Airframe Total Time:
Engine Manufacturer:
ELT:  C126 installed, not activated
Engine Model/Series:
Registered Owner: INDEPENDENCE AVIATION LLC
Rated Power:
Operator:  INDEPENDENCE AVIATION LLC
Operating Certificate(s) Held: None 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: COD
Distance from Accident Site:
Observation Time: 1155 MDT
Direction from Accident Site:
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 5 knots /
Turbulence Type Forecast/Actual: /
Wind Direction: 10°
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 30.19 inches Hg
Temperature/Dew Point: 16°C / 6°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Sheridan, WY (SHR)
Type of Flight Plan Filed: IFR
Destination: Billings, MT (BIL)
Type of Clearance: IFR
Departure Time: 1030 MDT
Type of Airspace: Class E

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 3 Fatal
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: On-Ground
Total Injuries: 4 Fatal
Latitude, Longitude:  44.605833, -109.419167

Rockwell 114 Commander, N4775W:  Fatal accident occurred May 17, 2015 near Laughlin/Bullhead Intl Airport (KIFP), Bullhead City, Arizona

James Dale Walker, USAF Colonel (Retired) 

Diana M. Soto


Greg Torres and Diana Soto


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


Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office;  Las Vegas, Nevada
Lycoming Engines; Mesa, Arizona 

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

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


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


http://registry.faa.gov/N4775W


Location: Laughlin, NV
Accident Number: WPR15FA163
Date & Time: 05/17/2015, 1800 PDT
Registration: N4775W
Aircraft: ROCKWELL COMMANDER 114
Aircraft Damage: Destroyed
Defining Event: Loss of engine power (partial)
Injuries: 3 Fatal, 1 Serious
Flight Conducted Under: Part 91: General Aviation - Personal

Analysis

The private pilot/owner reported that, during the climb to between about 300 and 400 ft above the ground, the engine started running roughly, and the airplane was not accelerating or climbing. The terrain ahead was rising, so the pilot turned right. Due to the low altitude and reduced engine power, the pilot chose to conduct an off-airport landing, during which he attempted to troubleshoot the engine issue without success. As the airplane continued to descend, the pilot saw houses and bushes ahead; he aimed the airplane away from the houses, and the airplane eventually hit trees and terrain about 4.6 nautical miles from the airport. A postimpact engine fire ensued.

Postaccident examination of the engine revealed that the turbocharger was seized and that the exhaust side of the turbowheel was severely eroded, which led to the engine running rough. A review of the airplane's maintenance records revealed that a turbocharger normalization system had been installed on the airplane under a supplemental type certificate (STC) 13 years before the accident. The STC's instructions for continued airworthiness required that the turbocharger normalization system be inspected every 100 hours. However, a review of the airplane's maintenance records revealed that the system had only been inspected once since its installation and that the inspection was completed 6 years before the accident. No other abnormalities were noted with the airframe or engine that would have precluded normal operation. It is likely that the eroded turbowheel would have been detected if the turbocharger normalization system had been inspected as required.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
A partial loss of engine power due to the turbocharger's seizure as a result of a severely worn turbowheel. Contributing to the accident was the failure of the pilot/owner to have the turbo normalization system inspected every 100 hours as required, which allowed erosion on the exhaust side of the turbowheel to go undetected.

Findings

Aircraft
Turbocharger - Fatigue/wear/corrosion (Cause)

Personnel issues
Scheduled/routine inspection - Maintenance personnel (Factor)

Environmental issues
Rough terrain - Contributed to outcome

Factual Information

History of Flight

Initial climb
Loss of engine power (partial) (Defining event)

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

On May 17, 2015, about 1800 Pacific daylight time, a Rockwell Commander 114B airplane, N4775W, crashed shortly after takeoff near Laughlin, Nevada. The private pilot/owner sustained serious injuries, and the three passengers sustained fatal injuries. The airplane was destroyed by impact forces and postcrash fire. The pilot was operating the airplane as a 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions existed at the accident site about the time of the accident, and no flight plan had been filed. The flight departed Laughlin/Bullhead International Airport (IFP), Bullhead City, Arizona, at 1756, destined for Goodyear, Arizona.

According to the pilot, he conducted an engine test run with no anomalies noted. At 1756, the tower controller cleared the flight for a straight-out departure to the south. During the climb to between about 300 and 400 ft above the ground, the engine started running roughly, and the airplane was not accelerating or climbing. The terrain ahead was rising, so the pilot turned right. Due to the low altitude and power, the pilot chose to conduct an off-airport landing, during which he attempted to troubleshoot the engine issue without success. As the airplane continued to descend, the pilot saw houses and bushes ahead; he aimed the airplane away from the houses, and the airplane eventually hit trees and terrain. A postimpact engine fire ensued.

Several witnesses near the accident site reported seeing the airplane flying at a very low altitude. One witness reported seeing it descend into trees followed by a fireball. Another witness reported seeing the airplane flying on a southbound track with its wings level and then descending out of his sight; he then saw an explosion followed by a fireball.

Pilot Information

Certificate: Private
Age: 59, 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: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 12/18/2014
Occupational Pilot: No
Last Flight Review or Equivalent: 07/12/2013
Flight Time:  2069 hours (Total, all aircraft), 1920.1 hours (Pilot In Command, all aircraft), 9 hours (Last 90 days, all aircraft), 2.2 hours (Last 30 days, all aircraft) 

The pilot held a private pilot certificate with an airplane single-engine land rating. The pilot was issued a Federal Aviation Administration third-class medical certificate on December 18, 2014, with the limitations that he must wear corrective lenses/glasses for distant vision and possess glasses for near vision.

Aircraft and Owner/Operator Information

Aircraft Make: ROCKWELL COMMANDER
Registration: N4775W
Model/Series: 114 B
Aircraft Category: Airplane
Year of Manufacture: 1976
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 14105
Landing Gear Type: Retractable - Tricycle
Seats: 4
Date/Type of Last Inspection: 10/28/2014, 100 Hour
Certified Max Gross Wt.: 3250 lbs
Time Since Last Inspection: 20 Hours
Engines: 1 Reciprocating
Airframe Total Time: 3436.5 Hours as of last inspection
Engine Manufacturer: Lycoming
ELT: C91  installed, not activated
Engine Model/Series: IO-540-T4A5D
Registered Owner: FUZZ AVIATION LLC
Rated Power: hp
Operator: On file
Operating Certificate(s) Held: None

The four-seat airplane, serial number 14105, was equipped with a Lycoming IO-540-T4A5D engine, serial number L-15117-48A. A review of the airplane's logbooks revealed that its last annual inspection was completed on October 28, 2014, at a total airframe time of 3,436.5 hours. A review of the airplane's maintenance records revealed a total time since engine overhaul of 1,148.8 hours.

The maintenance records showed that, on May 11, 1995, A McCauley 3-bladed propeller and a Woodward Governor were installed in accordance with STC No. SA4444NM. The original propeller installed on the Rockwell 114 was a 2-bladed Hartzell propeller model HC-C2YR-1BF.

The maintenance records also showed that, on April 18, 2002, an aftermarket turbo normalization system was installed on the engine under Supplemental Type Certificate (STC) Number SE00357DE. At that time, the total airframe time was 2,758.0 hours, and the time since engine overhaul was 480.3 hours. The STC's instructions for continued airworthiness required that the turbo normalization system be inspected every 100 hours.

On December 9, 2009, the turbo normalization system was removed, inspected, and reinstalled. The logbook entry noted that casting voids were found on the exhaust side of the turbocharger. The entry also noted that photographs had been provided to the turbocharger manufacturer for evaluation and that the manufacturer had deemed it airworthy. The engine logbooks contained no other entries indicating that the turbo normalization system was inspected in the 6 years before the accident.

IFP fueling records indicated that the airplane was last fueled on May 17, 2015, with 20.0 gallons of 100LL aviation fuel.  

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KIFP, 695 ft msl
Distance from Accident Site: 5 Nautical Miles
Observation Time: 0055 UTC
Direction from Accident Site: 58°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 13 knots / 21 knots
Turbulence Type Forecast/Actual: /
Wind Direction: 170°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 29.85 inches Hg
Temperature/Dew Point: 29°C / -2°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: BULLHEAD CITY, AZ (IFP)
Type of Flight Plan Filed: None
Destination: GOODYEAR, AZ (GYR)
Type of Clearance: None
Departure Time: 1756 MST
Type of Airspace:

Airport Information

Airport: LAUGHLIN/BULLHEAD INTL (IFP)
Runway Surface Type: N/A
Airport Elevation: 701 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 Serious
Aircraft Damage: Destroyed
Passenger Injuries: 3 Fatal
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: On-Ground
Total Injuries: 3 Fatal, 1 Serious
Latitude, Longitude: 35.116667, -114.639167 

The airplane crashed in Big Bend State Park. The main wreckage was located 4.6 nautical miles southwest of IFP. The airplane initially hit a mesquite tree, then impacted sand, and finally came to rest 120 ft south of the first impact point on a magnetic heading of 273°. The postimpact fire consumed most of the airplane.

Flight control continuity was established with all the flight control surfaces. The structure of all of the flight control surfaces and their corresponding counterweights were found in their correct positions. The landing gear were found in the retracted position. All of the cockpit components and instrumentation were consumed by fire.

The main wing assembly sustained thermal damage consistent with a fuel-fed fire. All of the wing components were found in their respective locations. Both flap assemblies were consumed by fire and found near the attachment point to the wing structure. The right wing was found up against the right side of the fuselage and was consumed by fire. 

Tests And Research

The wreckage was transported to Air Transport, Phoenix, Arizona, for further examination.

No abnormalities were noted with the airframe that would have precluded normal operation.

The engine was removed and disassembled. The propeller hub remained attached to the engine. The three propeller blades were present and exhibited thermal damage. The turbocharger, magnetos, and oil filter remained attached to the engine. All the other engine components were attached at their respective positions and exhibited thermal damage.


The turbocharger was found to be seized, it was disassembled, and examination of the turbowheel revealed that the blades were eroded. The overall diameter of the turbowheel was 2.451 inches. According to the manufacturer, a new turbowheel diameter is about 2.5 inches. It was also noted that the turbine impeller was significantly eroded and the heat shield was eroded which would allow hot gases to enter the bearing area and coke up the shaft.

Republic P-47D Thunderbolt, N1345B: Fatal accident occurred May 27, 2016 in Hudson River, New York, New York 


Bill Gordon


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


Additional Participating Entity: 

Federal Aviation Administration / Flight Standards District Office; Farmingdale, New York 

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


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


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

http://registry.faa.gov/N1345B 



Location: New York, NY
Accident Number: ERA16LA195
Date & Time: 05/27/2016, 1930 EDT
Registration: N1345B
Aircraft: REPUBLIC P 47D
Aircraft Damage: Substantial
Defining Event: Loss of engine power (total)
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Aerial Observation

Analysis 

The World War II-era fighter airplane was part of a three-ship formation performing a photo shoot. About 1,000 ft above the water, the pilot of the accident airplane made a distress call to air traffic control, stating that he had "smoke," and he subsequently ditched the airplane. The airplane landed on the water and subsequently sank. Another pilot in the formation reported that the canopy was partially open before the ditching. The pilot was unable to egress the airplane and drowned.

Examination of the engine revealed evidence of internal seizure. Damage to the inside of the crankcase prevented the removal of cylinders and disassembly of the engine. Oil and metallic fragments were found inside the engine's supercharger. Although the supercharger may have failed as the initiating event, the reason for the engine failure could not be determined due to the excessive internal damage to the engine.

Examination of the pilot's seat belt/shoulder harness restraints and canopy operation, including a functional test of the jettison T-handle, did not reveal evidence of any in-flight anomaly or failure. Although the airplane's operating instructions called for the pilot to jettison the canopy before ditching, the pilot did not do so, and was subsequently unable to fully open the canopy and egress the airplane as it sank.

Toxicology testing revealed diphenhydramine, an impairing medication that causes sedation, altered mood, and impaired cognitive and psychomotor performance in blood and urine specimens. However, the level of diphenhydramine in blood was too low to quantify and therefore any effects from it likely did not contribute to the accident.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
A catastrophic engine failure of undetermined origin, which resulted in a total loss of engine power and subsequent ditching. Contributing to the accident was the pilot's failure to jettison the canopy before ditching, which resulted in his inability to egress the airplane as it sank.

Bill Gordon

Findings

Aircraft
Recip eng supercharger - Failure (Cause)
Recip eng cyl section - Damaged/degraded (Cause)

Personnel issues
Use of equip/system - Pilot (Factor)

Not determined
Not determined - Unknown/Not determined (Cause)

Factual Information

History of Flight

Enroute-cruise
Loss of engine power (total) (Defining event)

Emergency descent
Ditching



On May 27, 2016, about 1930 eastern daylight time, a Republic P-47D, N1345B, ditched in the Hudson River near New York, New York, following a total loss of engine power. The commercial pilot was fatally injured and the airplane was substantially damaged. The experimental, exhibition-category airplane was registered to a corporation and was operated by the American Airpower Museum under the provisions of 14 Code of Federal Regulations Part 91 as an aerial observation flight. Day visual meteorological conditions prevailed at the time of the accident, and no flight plan was filed. The local flight originated from Republic Airport (FRG), Farmingdale, New York, about 1900.

The accident airplane was part of a three-ship formation participating in a photo shoot. The #2 pilot in the formation reported that they flew along the beach, on the south side of Long Island, then into the visual flight rules corridor next to John F Kennedy International Airport (JFK). They were about 1,100 ft above the water and proceeding north along the Hudson River about 140 knots. Over the radio, he heard the pilot of the accident airplane report that he had "smoke." (The pilot made a distress call to the Newark Liberty International Airport (EWR) air traffic control tower.) The #2 pilot subsequently saw smoke from the accident airplane then saw the propeller "seize up." The accident pilot maneuvered the airplane for a forced landing in the Hudson River. The #2 pilot observed that the accident airplane's canopy was only partially open; as the airplane descended, touched down on the water, and sank a few seconds later in the Hudson River south of the George Washington Bridge. Attempts by first responders to rescue the pilot were unsuccessful. 

Pilot Information

Certificate: Commercial; Private
Age: 56, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land; Single-engine Sea
Seat Occupied: Single
Other Aircraft Rating(s): Helicopter
Restraint Used: 5-point
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: 08/05/2015
Occupational Pilot: Yes
Last Flight Review or Equivalent:
Flight Time: 6400 hours (Total, all aircraft) 

The pilot held a commercial pilot certificate with airplane single- and multi-engine land, airplane single-engine sea, rotorcraft-helicopter, and instrument airplane ratings. He also held a Federal Aviation Administration (FAA) airframe and powerplant mechanic certificate. The pilot held an FAA second-class medical certificate and reported 6,400 total hours of flight experience on his application for that certificate, dated August 5, 2015.



Aircraft and Owner/Operator Information

Aircraft Make: REPUBLIC
Registration: N1345B
Model/Series: P 47D D
Aircraft Category: Airplane
Year of Manufacture: 1945
Amateur Built: No
Airworthiness Certificate: Experimental
Serial Number: 44-90447
Landing Gear Type: Retractable - Tailwheel
Seats: 1
Date/Type of Last Inspection: 05/09/2015, Condition
Certified Max Gross Wt.: 17500 lbs
Time Since Last Inspection:
Engines:  1 Reciprocating
Airframe Total Time: 553 Hours as of last inspection
Engine Manufacturer: Pratt and Whitney
ELT:
Engine Model/Series: R-2800-69
Registered Owner: PT-17 INC
Rated Power: 2335 hp
Operator: American Airpower Museum
Operating Certificate(s) Held: None 

The airplane was a low-wing, single-seat, World War II-era fighter airplane with retractable landing gear in a tailwheel configuration. It was powered by a Pratt and Whitney R2800-69, 18-cylinder radial engine and a Hamilton Standard four-bladed, constant-speed propeller.

According to maintenance logbook entries, a condition inspection was completed on May 9, 2015, at a Hobbs time of 553.0 hours. At that time, the engine oil was changed and the oil screen was inspected; no contaminants were observed.

A representative of the corporation that owned the airplane reported that the engine was "low time, less than 400 hours" and that the airplane was due for its next condition inspection on June 1, 2016. The airplane was maintained in a hangar, and the engine "ran well with no recent complaints."



Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: EWR, 17 ft msl
Distance from Accident Site: 9 Nautical Miles
Observation Time: 1751 EDT
Direction from Accident Site: 240°
Lowest Cloud Condition: Few / 5500 ft agl
Visibility:  10 Miles
Lowest Ceiling: Broken / 25000 ft agl
Visibility (RVR):
Wind Speed/Gusts: 8 knots /
Turbulence Type Forecast/Actual: / None
Wind Direction: 150°
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 29.99 inches Hg
Temperature/Dew Point: 28°C / 19°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Farmingdale, NY (FRG)
Type of Flight Plan Filed: None
Destination: Farmingdale, NY (FRG)
Type of Clearance: VFR
Departure Time: 1900 EDT
Type of Airspace: Special 

EWR was located about 9 miles southwest of the accident location. The 1951 weather observation included wind from 150° at 8 knots, visibility 10 statute miles, few clouds at 5,500 ft, scattered clouds at 18,000 ft, a broken ceiling at 25,000 ft, temperature 28°C, dew point 19°C, and altimeter setting 29.99 inches of mercury.

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: 40.791667, -73.985278 (est)

The wreckage was recovered from the river the following day near the 79th Street Boat Basin and transported to the West 30th Street Heliport, New York, New York. An initial examination of the wreckage revealed that the airframe was generally intact. The engine remained attached to the airframe. A cursory examination of the engine revealed that the No. 18 cylinder was damaged, consistent with an in-flight occurrence. Oil was present on the exterior of the engine.

The wreckage was moved to a storage facility where additional examinations were performed by an FAA inspector. The inspector noted that the engine was internally seized and would not rotate. He tried to remove the cylinders; however, all cylinders were damaged and could not be removed from the crankcase. Metallic debris and oil were found inside the supercharger. Four intake manifolds were removed for examination; they were also oil-soaked and contained metal particles. Due to the internal damage to the engine and the inability to remove cylinders, further examination of the engine was not attempted.

Medical And Pathological Information

The Office of the Chief Medical Examiner, City of New York, performed an autopsy of the pilot. The cause of death was drowning, and the manner of death was accident.

The FAA's Bioaeronautical Research Sciences Laboratory, Oklahoma City, Oklahoma, performed toxicology testing on specimens from the pilot. Diphenhydramine was detected in the blood and urine at levels too low to quantify.

Diphenhydramine is a sedating antihistamine used to treat allergy symptoms and as a sleep aid and carries the following Federal Drug Administration warning: "May impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g. driving, operating heavy machinery)."

Survival Aspects

An examination of the cockpit seat belt/harness restraints and the canopy system was performed by the NTSB Survival Factors Group Chairman. When examined at the wreckage storage facility, the cockpit canopy was in the full-open position. The cockpit control stick and instrument panel were undamaged. The pilot seat, which was designed to move up and down by engaging a lever adjacent to the seat, operated in a normal manner. The four-point seat belt restraint system consisted of a lap belt and shoulder harness. The system was fastened and unfastened by the investigator and functioned in a normal manner.

The cockpit canopy was designed to be operated by hand, by a motor controlled from an internal switch in the cockpit, or by an external switch located forward of the left of the cockpit window in an access panel. The extremes of travel were limited by two limit switches mounted on the deck behind the pilot seat. The entire operating mechanism was covered by the aft portion of the canopy while in the closed position.

To operate the canopy from inside the airplane, the internal lock release is pushed forward to the full stop. This action disengages the clutch on the canopy motor. While holding forward pressure on the lock release, the pilot can manually move the canopy freely on its rails. To automatically move the canopy, the pilot would select the open or closed position on the canopy switch, which was located in front of the lock release on the left cockpit sidewall.

An examination of the internal and external lock release mechanism was performed. Both lock releases disengaged the motor and allowed the canopy to move freely on its rails. The automatic motor switches were not tested due to flammable fluids in the area and lack of a power source.

To jettison the canopy, the pilot was required to pull the jettison T-handle mounted on the front frame of the canopy. This action allowed the locking pins to be pulled from the two jettison fittings that held the canopy to the roller assemblies. All three fittings would then be free, and the canopy could be jettisoned in-flight or removed on the ground. An examination of the jettison handle was performed. The T-handle was pulled by the investigator and the canopy subsequently released from the rail and departed the cockpit area.

The procedures for ditching the airplane were found in the pilot's Flight Operating Instructions (AN 01-65BC-1A). Section IV, bullet 8 on page 37 described the procedures for ditching:

"If it becomes necessary to abandon the airplane over water and it is not desirable to bail out, the following procedure is suggested. (1) Make sure safety belt and shoulder harness are secure. (2) Lower flaps. (3) Jettison canopy. (4) Make normal approach glide into the wind. Hold off until stall speed is reached, then set down tail first. (5) Ditch into the wind on upslope wave."

The pilot's flight helmet was recovered at the accident scene. The flight helmet shell showed no signs of impact damage and all functions of the helmet operated normally.

Beechcraft B200 Super King Air, N52SZ: Fatal accident occurred October 30, 2014 at Wichita Dwight D. Eisenhower National Airport (KICT), Kansas 


Mark Goldstein

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

Additional Participating Entities: 
Federal Aviation Administration / Flight Standards District Office; Dallas, Texas 
Textron Aviation; Wichita, Kansas
Hartzell Propeller; Piqua, Ohio

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


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

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

https://registry.faa.gov/N52SZ

Location: Wichita, KS
Accident Number: CEN15FA034
Date & Time: 10/30/2014, 0948 CDT
Registration: N52SZ
Aircraft: RAYTHEON AIRCRAFT COMPANY B200
Aircraft Damage: Destroyed
Defining Event: Loss of engine power (partial)
Injuries: 4 Fatal, 2 Serious, 4 Minor
Flight Conducted Under: Part 91: General Aviation - Ferry

Analysis

The airline transport pilot was departing for a repositioning flight. During the initial climb, the pilot declared an emergency and stated that the airplane "lost the left engine." The airplane climbed to about 120 ft above ground level, and witnesses reported seeing it in a left turn with the landing gear extended. The airplane continued turning left and descended into a building on the airfield. A postimpact fired ensued and consumed a majority of the airplane.

Postaccident examinations of the airplane, engines, and propellers did not reveal any anomalies that would have precluded normal operation. Neither propeller was feathered before impact. Both engines exhibited multiple internal damage signatures consistent with engine operation at impact. Engine performance calculations using the preimpact propeller blade angles (derived from witness marks on the preload plates) and sound spectrum analysis revealed that the left engine was likely producing low to moderate power and that the right engine was likely producing moderate to high power when the airplane struck the building. A sudden, uncommanded engine power loss without flameout can result from a fuel control unit failure or a loose compressor discharge pressure (P3) line; thermal damage prevented a full assessment of the fuel control units and P3 lines. Although the left engine was producing some power at the time of the accident, the investigation could not rule out the possibility that a sudden left engine power loss, consistent with the pilot's report, occurred.

A sideslip thrust and rudder study determined that, during the last second of the flight, the airplane had a nose-left sideslip angle of 29°. It is likely that the pilot applied substantial left rudder input at the end of the flight. Because the airplane's rudder boost system was destroyed, the investigation could not determine if the system was on or working properly during the accident flight. Based on the available evidence, it is likely that the pilot failed to maintain lateral control of the airplane after he reported a problem with the left engine. The evidence also indicates that the pilot did not follow the emergency procedures for an engine failure during takeoff, which included retracting the landing gear and feathering the propeller.

Although the pilot had a history of anxiety and depression, which he was treating with medication that he had not reported to the Federal Aviation Administration, analysis of the pilot's autopsy and medical records found no evidence suggesting that either his medical conditions or the drugs he was taking to treat them contributed to his inability to safely control the airplane in an emergency situation.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's failure to maintain lateral control of the airplane after a reduction in left engine power and his application of inappropriate rudder input. Contributing to the accident was the pilot's failure to follow the emergency procedures for an engine failure during takeoff. Also contributing to the accident was the left engine power reduction for reasons that could not be determined because a postaccident examination did not reveal any anomalies that would have precluded normal operation and thermal damage precluded a complete examination.

Findings

Aircraft
Lateral/bank control - Not attained/maintained (Cause)
Engine out control - Not attained/maintained (Cause)
Engine (turbine/turboprop) - Not specified (Factor)

Personnel issues
Aircraft control - Pilot (Cause)
Incorrect action selection - Pilot (Cause)
Lack of action - Pilot (Factor)
Identification/recognition - Pilot
Decision making/judgment - Pilot

Factual Information

HISTORY OF FLIGHT

On October 30, 2014, at 0948 central daylight time, a Raytheon Aircraft Company King Air B200 airplane, N52SZ, impacted the FlightSafety International (FSI) building located on the airport infield during initial climb from Wichita Mid-Continent Airport (ICT), Wichita, Kansas. The airline transport pilot, who was the sole occupant, was fatally injured, and the airplane was destroyed. Three building occupants were fatally injured, two occupants sustained serious injuries, and four occupants sustained minor injuries. The airplane was registered to and operated by Gilleland Aviation, Inc., Georgetown, Texas, under the provisions of 14 Code of Federal Regulations Part 91 as a ferry flight. Visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed. The flight was originating from ICT at the time of the accident and was en route to Mena Intermountain Municipal Airport (MEZ), Mena, Arkansas.

The ICT air traffic controllers stated that the accident flight was cleared for takeoff on runway 1R and instructed to fly the runway heading. After becoming airborne, the pilot declared an emergency and stated that the airplane "lost the left engine." The airplane then entered a shallow left turn, continued turning left, and then descended into a building. A controller called aircraft rescue and firefighting on the "crash phone" just before impact. The controllers observed flames and then black smoke coming from the accident site.

Witnesses in the Cessna Service Center building on the east side of runway 1R also observed the airplane departing runway 1R. They indicated that the airplane then porpoised several times before making a left turn. The airplane continued the left turn, barely cleared the top of a hangar on the west side of runway 1R, and then descended into a building. The witnesses reported that the landing gear was extended and that they could not clearly hear the sound of the engines. The airplane's altitude appeared to be less than 150 ft above ground level (agl).

Airport surveillance video cameras captured the last 9 seconds of the flight. The videos showed that the airplane was turning left and in a nose-left sideslip as it overflew a hangar. The cameras showed that the airplane was about 120 ft agl when it impacted the FSI building, and a postimpact explosion and fire ensued.


 
Mark Goldstein

PERSONNEL INFORMATION

The pilot, age 53, held an airline transport pilot (ATP) certificate with ratings for airplane single-engine and multiengine land. On August 4, 2014, he was issued a Federal Aviation Administration (FAA) second-class medical certificate with the limitation that he must wear corrective lenses.

The pilot's flight time logbook was not located during the investigation. At the time of his August 2014 medical examination, he reported a total flight time of 3,067 hours with 200 hours in the preceding 6 months. A review of the pilot's flight training records from FSI, dated September 18, 2014, revealed that he had accumulated 3,139 total flight hours, 2,843 hours of which were in multiengine airplanes. The King Air B200 did not require a type rating.

From September 4 to 19, 2014, the pilot received Beechcraft King Air 300 series initial training at FSI, Wichita, Kansas. The training was specifically for the King Air 350 Proline 21 model and included 58.5 ground training hours, 12 briefing hours, 14 pilot-flying simulator hours, and 12 pilot-not-flying hours. During the course, the pilot reviewed and completed the required emergency procedures. The pilot satisfactorily completed the course with an examination that included 2.5 hours written/oral examination time and 2.2 simulator flying hours.

On September 19, 2014, the pilot was issued an FAA ATP temporary airman certificate with the following ratings and limitations: airplane multiengine land ratings for Beechcraft (BE)-300, BE-400, Cessna (CE)-525, Dassault Falcon (DA)-10, Learjet (LR)-45, LR-60, LR-JET, Mitsubishi (MU)-300 airplanes; second-in-command privileges only for BE-400, CE-525, DA-10, LR-45, LR-60, LR-JET, and MU-300 airplanes; and private pilot privileges for airplane single-engine land.

AIRCRAFT INFORMATION

The accident airplane was bought by Gilleland Aviation, Inc., Georgetown, Texas, on October 28, 2014. The King Air B200 was a six-seat, low-wing, multiengine airplane manufactured in 2000. The airplane was powered by two Pratt & Whitney PT6A-42 turboprop engines that each drove a Hartzell four-bladed, hydraulically operated, constant-speed propeller with full feathering and reversing capabilities. The propeller blade angle settings for this installation were -11.0° ± 0.5° reverse, 18.2° ± 0.1° low, and 85.8° ± 0.5° feather.

On October 30, 2014, at 0740, the airplane was refueled at ICT by Signature Flight Support. The two outboard fuel tanks (usable 193-gallon capacity each) were reported to have been filled to capacity. The two auxiliary fuel tanks (usable 79-gallon capacity each) were reported to be empty. The fueling receipt noted that 57 gallons of Jet A fuel were added to the left main tank and that 53 gallons of Jet A fuel were added to the right main tank.

Maintenance

A review of the airplane maintenance records found that major scheduled maintenance was completed at Hawker Beechcraft Services, Wichita, Kansas, on October 22, 2014. The maintenance included left and right engine hot-section inspections and an overhaul of the right propeller. At the time of the accident, the airplane had accumulated 1.4 hours and 2 cycles since it was released to service on October 22, 2014. The review found no maintenance record discrepancies that would have affected the operation or performance of the airplane.

Postmaintenance Test Flights

During the October 22, 2014, Hawker Beechcraft postmaintenance test flight, the following discrepancies were noted:

• The left throttle lever was ahead of the right by about 1/4 of the lever knob.

• The cabin environmental system pressurization leak rate was high.

All other systems functioned normally. The engine interturbine temperature (ITT) gauge indications were split, indicating that one of the engines was operating more efficiently than the other; however, both engines were able to achieve maximum power per the pilot's operating handbook (POH) performance charts with no temperature ITT exceedance.

Maintenance was performed to address the throttle matching and cabin environmental system discrepancies, and a second maintenance test flight was conducted on October 27, 2014. During the flight, it was noted that the throttle lever mismatch was corrected. The environmental system bleed air valves (flow packs) pressurization leak rates were acceptable, although one was weaker than the other when tested independently. No other anomalies were noted.

Following the flight, maintenance personnel confirmed that the left flow pack output was higher than the right. Both sides of the system passed maintenance manual and ground operational checks. To better understand these findings, the airplane owner agreed that the left and right environmental system flow packs, electronic controllers, and thermistors should be swapped.

Rudder Boost System

The airplane was equipped with a rudder boost system to aid the pilot in maintaining directional control in the event of an engine failure or a large variation of power between the engines. The rudder cable system incorporated two pneumatic rudder-boosting servos that would actuate the cables to provide rudder pressure to help compensate for asymmetrical thrust. During operation, a differential pressure valve would accept bleed air pressure from each engine. When the pressure varied between the bleed air systems, the shuttle in the differential pressure valve would move toward the low pressure side. As the pressure differential reached a preset tolerance, a switch on the low pressure side would close, activating the rudder boost system. The system was designed only to help compensate for asymmetrical thrust; the pilot was to accomplish appropriate trimming.

The system was controlled by a toggle switch, placarded "RUDDER BOOST – OFF" and located on the pedestal below the rudder trim wheel. The switch was to be turned on before flight. A preflight check of the system could be performed during the run-up by retarding the power on one engine to idle and advancing power on the opposite engine until the power difference between the engines was great enough to close the switch that activates the rudder boost system. Movement of the appropriate rudder pedal (left engine idling, right rudder pedal would move forward) would be noted when the switch closed, indicating that the system was functioning properly for low engine power on that side. The check was to be repeated with opposite power settings to check for movement of the opposite rudder pedal. Moving either or both of the bleed air valve switches in the copilot's subpanel to the "INSTR & ENVIR OFF" position would disengage the rudder boost system.

Autofeathering System

The airplane was equipped with an autofeathering system that provided a means of automatically feathering the propeller in the event of an engine failure. The system was armed using a switch on the pilot's subpanel placarded "AUTOFEATHER – ARM – OFF – TEST." With the switch in the "ARM" position and both power levers above about 90 percent N1, the green L and R AUTOFEATHER annunciators located on the caution/advisory panel would illuminate, indicating that the system was armed. If either power lever was not above about 90 percent N1, the system would be disarmed, and neither annunciator would be illuminated. When the system was armed and the torque on a failing engine dropped below about 410 ft-lbs, the operative engine's autofeather system would be disarmed. When the torque on the failing engine dropped below about 260 ft-lbs, the oil was dumped from the servo, and the feathering spring and counterweights feathered the propeller.

For King Air B200 airplanes equipped with Hartzell propellers, the propeller autofeather system must be operable for all flights and be armed for takeoff, climb, approach, and landing. A preflight system test, as described in the King Air POH, Section IV, "NORMAL PROCEDURES," was required. Since an engine would not actually be shut down during a test, the AUTOFEATHER annunciator for the engine being tested would cycle on and off as the torque oscillated above and below the 260 ft-lbs setting.

Emergency Procedure

The King Air B200 POH outlined an Engine Failure During Takeoff (at or above V1) Takeoff Continued procedure, which stated, in part, the following:

1. Power –> maximum allowable

2. Airspeed –> maintain (takeoff speed or above)

3. Landing gear –> up

Note: If the autofeather system…is being used, do not retard the failed engine power lever until the autofeather system has completely stopped the propeller rotation. To do so will deactivate the autofeather circuit and prevent automatic feathering.

4. Propeller lever (inoperative engine) –> feather (or verify that propeller is feathered if autofeather is installed)

METEOROLOGICAL INFORMATION

At 0953, the automated weather observation at ICT reported wind from 350 degrees and 16 knots, visibility of 10 miles, a few clouds at 15,000 ft, temperature 59° F, dew point 37° F, and altimeter setting 30.12 inches of Mercury.

COMMUNICATIONS

The following is a chronological summary of the communications between the accident pilot and the ICT air traffic controllers.

0938 The pilot requested an IFR clearance to MEZ. Clearance Delivery read the clearance to the pilot, and the pilot read back the clearance correctly.

0940 The pilot requested taxi clearance with the automatic terminal information service (ATIS). Ground Control issued a taxi clearance to runway 1R at Echo 3 intersection via taxiways Alpha 5, Alpha, Bravo, Echo. The pilot read back the instructions correctly.

0941 Ground Control reverified that the accident pilot had ATIS Hotel.

0942  The pilot advised he had to perform a quick run-up and asked Ground Control for a location to complete the run-up. Ground Control advised him to proceed to the end of the taxiway or to the Echo 3 intersection.

0947 The pilot requested and was cleared for takeoff by Local Control on runway heading. The pilot read back the instructions correctly.

0948 The pilot declared an emergency and advised that he "lost the left engine."

FLIGHT RECORDERS

Cockpit Voice Recorder

The airplane was equipped with a Fairchild Model A100S cockpit voice recorder (CVR). The unit was removed from the wreckage and sent to the National Transportation Safety Board (NTSB) Vehicle Recorder Laboratory for download. A timeline generated from the CVR recording determined that the time duration from liftoff to building impact was about 26 seconds.

Nonvolatile Memory

The airplane was equipped with a Sandel ST3400 terrain awareness and warning system and radio magnetic indicator unit. This unit was retained and examined by the NTSB Vehicle Recorder Laboratory. The examination revealed that the unit sustained severe thermal damage and that the nonvolatile memory contents were destroyed; therefore, no data were available for recovery.

WRECKAGE AND IMPACT INFORMATION

General

The accident site was located at latitude 37° 39.592 N, longitude 97° 25.490 W, at an elevation of 1,363 ft mean sea level. The airplane struck the northeast corner of the FSI building, which housed several flight simulators. A large simulator room on the north end was the point of impact and sustained most of the structural and fire damage. The simulator room was about two stories high, about 198 ft long (east-west), and about 42 ft deep (north-south). Most of the airplane wreckage was distributed from the northeast corner toward the southwest corner of the room and remained on the roof of the simulator room and the attached buildings.

A postimpact fired ensued and consumed a majority of the airplane. The left engine, propeller, and left main landing gear were found just inside the building on the ground level. A majority of the left outboard wing, flap, and aileron were found at the foot of the building's exterior east wall. The fuselage, tail section, cockpit, right engine, and right main landing gear were located on the conjoined buildings' rooftops. The cockpit, instrument panels, right engine, and right landing gear strut were located about 160 ft from the initial impact point to the south on the roof of the simulator room. The right engine and propeller came to rest next to the cockpit.

The cabin area of the fuselage and empennage came to rest inverted on the lower, west roof. The cabin area was mostly consumed by the postimpact fire. Portions of the wing center section and all of the tail section were located to the south on the lower roof of the conjoined building. The right wing had separated and came to rest on the roof of another attached building about 120 ft from the initial impact point. A separated portion of a propeller blade was found near the right wing. A separated propeller blade tip was found in a parking lot about 200 ft northeast from the initial impact point. The tail section sustained severe thermal damage, but remained recognizable. The horizontal stabilizers remained attached to the vertical stabilizer with the elevators attached. The elevator trim tabs remained attached to their respective elevator. The vertical stabilizer remained attached to the aft fuselage with the rudder attached. The rudder trim tab remained attached to the rudder.

The left main landing gear was found extended with the down-lock latched into place. The structure of the right main landing gear was not intact. The strut, wheel, and tire of the nose gear assembly were found in the parking lot on the north side of the building. Witness and video evidence, which is discussed in the "ADDITIONAL INFORMATION" section of this report, confirmed that the landing gear were extended before impact.

One of the four rudder cables in the tail section had the ball swage fitting still attached. The other three cables (one rudder and two elevators) were separated with rusty coloration at the separation point. The three cables were stiff 3 to 9 inches from the fracture surface, consistent with high-temperature oxidation and separation. The rest of the three cables remained flexible, which was typical of a control cable.

Rudder flight control continuity was established from the rudder to the flight control cables. One cable terminated at the aft fuselage in a thermal separation, and the other cable terminated at a more forward position at a cable end.

Down elevator control continuity was confirmed from the elevator surface to the aft fuselage. The up elevator aft bell crank segment was separated with the flight control cable attached. Both cables terminated at the aft fuselage in thermal separations.

A secondary examination of the flight control systems was conducted at a secure storage facility. The primary and secondary flight control cables were all accounted for from the cockpit to each respective flight control surface with cable separations that exhibited signatures consistent with thermal separation, tensile overload, and/or being cut during recovery.

Flap Actuators

The only flap actuator observed was the outboard left flap actuator, and the position equated to about 10° extended. A secondary examination of the flap switch handle determined that it was in the UP detent.

The flaps had three positions: UP, APPROACH, and DOWN. UP was 0°, APPROACH was 14° (+ or - 1°), and DOWN was 35° (+1°/-2°). According to the POH, the flaps could be set to UP or APPROACH during takeoff. Any of the three flap positions could be selected by moving the flap switch handle up or down to the selected position indicated on the pedestal. The flaps could not be stopped in between any of the three positions.

Trim Actuators

The rudder trim actuator position equated to greater than 15° tab trailing edge left (rudder right, nose right). The left and right elevator trim actuator positions equated to 0° trim. The right aileron trim actuator position equated to about 9° tab trailing edge up (right wing up).

Rudder Boost and Autofeathering Systems

The rudder boost system, autofeathering system, and their respective cockpit controls were mostly consumed by the postimpact fire. Due to the extensive thermal damage, an examination of the systems could not be accomplished.

Powerplants

The engines and propellers were relocated to a secure hangar where airframe components were removed, and the propellers were separated from the engines.

Engine teardown examinations were performed from November 3 to 5, 2014, at a Pratt & Whitney service center. Although the engine inlet housings, gearbox cases, and the accessory housings and tubing were severely fire-damaged, the core engines were intact and could be fully evaluated. No evidence of preimpact failure was found. Both engine compressors exhibited impact damage characteristic of foreign object damage. Both engines' gas producer and power turbine rotor gas path components displayed circumferential friction, rub, and scoring damage characteristic of damage that occurs when normal operating clearances between rotating and stationary components are momentarily lost as the engine experiences abnormal axial and radial loading during an impact sequence. The left engine power turbine shaft was separated torsionally, consistent with the sudden stoppage of the propeller (blade strike) while the power turbine shaft continued to rotate.

The left engine fuel pump and fuel control housings were thermally destroyed; examination of the remaining (steel) engine fuel system and propeller governor system components and tubing connections recovered from the debris revealed no anomalies. The extensive thermal damage prevented full assessment of the fuel metering system, including the fuel control units and compressor discharge pressure lines (P3) to both engines. The left engine propeller governor and propeller overspeed governor were examined and tested at Woodward, Inc., Rockford, Illinois, with no preimpact anomalies noted.

The propellers were examined in Wichita from November 1 to 3, 2014, and again at Hartzell Propellers, Inc., Piqua, Ohio, on September 9 and 10, 2015. Fracture features and dimensions of the recovered propeller blade segments identified them as the missing outboard sections of two consecutive left propeller blades. Both blades were separated chordwise and exhibited leading edge tearing signatures. The left propeller blade damage also included other leading edge dents and tearing, aft bending, and moderate twisting. All of the propeller damage was consistent with impact loading or postimpact fire. The right propeller blades were thermally consumed.

All eight of the propeller preload plates displayed witness marks consistent with abnormal loading (blade strike). Although witness marks can reflect impact blade angles from later stages of the impact sequence, carefully analyzed preload plate witness marks can be a relatively reliable indication of the preimpact blade angle for this propeller design. The angular positions of the witness marks were used to approximate blade position at the time each impact occurred. The preload plate witness marks of the respective propellers indicated that the left propeller was likely at a 17° blade angle upon initial impact, and the right propeller was likely at a 22.5° blade angle upon initial impact.

Engine performance calculations using the derived blade angles and sound spectrum analysis-based findings (see the "CVR Sound Spectrum Analysis" section of this report) indicated that the left engine was likely operating but producing low to moderate power when the airplane struck the building and that the right engine was operating normally and producing moderate to high power when the airplane struck the building.

MEDICAL AND PATHOLOGICAL INFORMATION

This 53-year-old pilot had been an air traffic controller for more than 20 years at ICT and retired in 2013. Since his first medical certification in 1980, the pilot had reported thyroid disease, hernias, and recurrent symptomatic kidney stones to the FAA. Beginning in 1997, he had episodes of anxiety and depression, which required intermittent treatment with medication. During the first episode, he was unable to work for a certain time. A second episode began in October 2013 and continued through the accident date. He did not report his recurrent anxiety or his use of buspirone and escitalopram to the FAA. However, he visited his primary care physician about 1 month before the accident and was noted to be stable on the medications. In addition, the pilot had a procedure to treat kidney stones in 2013 that he did not report to the FAA.

On November 3, 2014, the Regional Forensic Science Center, Sedgwick County, Kansas, performed an autopsy on the pilot. The cause of death was determined to be thermal injuries and smoke inhalation and the manner of death was determined to be an accident. According to the autopsy report, a thin plastic medical catheter was identified in the pilot's pelvis, but it was not further described in the report. The Regional Forensic Science Center also conducted toxicology testing of the pilot's heart blood, which identified carboxyhemoglobin at 39 percent, but no other tested for substances were found.

Toxicology testing performed by the Bioaeronautical Research Laboratory at the FAA's Civil Aerospace Medical Institute identified buspirone and citalopram and its metabolite n-desmethylcitalopram in the pilot's heart blood and urine. In addition, the carboxyhemoglobin was 35 percent; no ethanol, cyanide, or any other tested for substances were identified. Buspirone, also named BuSpar, is an anxiolytic prescription medication. Buspirone is different from other anxiolytics in that it has little, if any, typical anti-anxiety side effects, such as sedation and physical impairment, but it does carry a warning, "May impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery)." Citalopram is a prescription antidepressant, also named Celexa, which carries a warning, "May impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery)."

ADDITIONAL INFORMATION

Airport Surveillance Video Data

Airport surveillance videos, which captured the last 9 seconds of the flight, including an image of the airplane within 1 second of impact, was used to estimate the airplane's trajectory and speed. The estimations indicated that the airplane's groundspeed increased from 85 to 92 knots and that the descent rate increased from about 0 to 1,600 ft per minute just before impact. The airplane's altitude reached a maximum of about 120 ft agl before it descended into the building.

Sideslip Thrust and Rudder Study

The NTSB conducted a sideslip thrust and rudder study based on information from the surveillance videos. This study evaluated the relationships between the airplane's sideslip angle, thrust differential, and rudder deflection. Calculations made using multiple rudder deflection angles showed that full right rudder deflection would have resulted in a sideslip angle near 0°, a neutral rudder would have resulted in an airplane sideslip angle between 14° and 19°, and a full left rudder deflection would have resulted in an airplane sideslip angle between 28° and 35° airplane nose left. Calculation of the airplane's sideslip angle as captured in the image of the airplane during the last second of flight showed that the airplane had a 29° nose-left sideslip, which would have required the application of a substantial left rudder input.

CVR Sound Spectrum Analysis

A sound spectrum analysis was completed using harmonic signatures recorded on the CVR from the cockpit area microphone and an unconnected microphone jack. A graph of the harmonic signatures from the cockpit area microphone show signatures that likely represent the propeller blade tip sounds and propeller rpm diverging, consistent with one propeller rpm decreasing.

A graph of harmonic signatures from the unconnected microphone jack revealed electrical noise signatures generated from the engines. At the beginning of the graph, these signatures (two for each engine) increased, corresponding to increasing engine rpm. Later, two of the signatures began to decrease, consistent with one engine's rpm decreasing.

History of Flight

Initial climb
Loss of engine power (partial) (Defining event)

Emergency descent
Collision with terr/obj (non-CFIT)
Loss of control in flight 

Pilot Information

Certificate: Airline Transport
Age: 53, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
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: 08/04/2014
Occupational Pilot: Yes
Last Flight Review or Equivalent: 09/19/2014
Flight Time: 3139 hours (Total, all aircraft) 

Aircraft and Owner/Operator Information

Aircraft Make: RAYTHEON AIRCRAFT COMPANY
Registration: N52SZ
Model/Series: B200
Aircraft Category: Airplane
Year of Manufacture:
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: BB-1686
Landing Gear Type: Tricycle
Seats:
Date/Type of Last Inspection: 10/22/2014, Continuous Airworthiness
Certified Max Gross Wt.: 12500 lbs
Time Since Last Inspection: 1.4 Hours
Engines: Turbo Prop
Airframe Total Time: as of last inspection
Engine Manufacturer: Pratt & Whitney
ELT: Installed, not activated
Engine Model/Series: PT6A-42
Registered Owner: Gilleland Aviation Inc
Rated Power: 850 hp
Operator: Gilleland Aviation Inc
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KICT, 1340 ft msl
Distance from Accident Site: 0 Nautical Miles
Observation Time: 0953 CDT
Direction from Accident Site: 183°
Lowest Cloud Condition: Few / 15000 ft agl
Visibility:  10 Miles
Lowest Ceiling:
Visibility (RVR):
Wind Speed/Gusts: 16 knots /
Turbulence Type Forecast/Actual: /
Wind Direction: 350°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 30.12 inches Hg
Temperature/Dew Point: 15°C / 3°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Wichita, KS (ICT)
Type of Flight Plan Filed: IFR
Destination: MENA, AR (MEZ)
Type of Clearance: IFR
Departure Time: 0947 CDT
Type of Airspace: Air Traffic Control; Class C

Airport Information

Airport: WICHITA MID-CONTINENT (ICT)
Runway Surface Type: Concrete
Airport Elevation: 1333 ft
Runway Surface Condition: Dry
Runway Used: 01R
IFR Approach: None
Runway Length/Width: 7301 ft / 150 ft
VFR Approach/Landing: Forced Landing

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: On-Ground
Ground Injuries: 3 Fatal, 2 Serious, 4 Minor
Aircraft Explosion: On-Ground
Total Injuries: 4 Fatal, 2 Serious, 4 Minor
Latitude, Longitude:  37.652500, -97.429722 (est)

4 comments:

Anonymous said...

I do hope that the law suit clears up any possibility of the NTSB withholding any crash investigation records necessary to aid in the complete investigation of any accident.

Anonymous said...

All tragic accidents.

May those lost RIP and those injured a full recovery.

It would be interesting to compare the suits filed to the respective accident reports.

Jim B said...


You will never satisfy anyone who is paid to be dissatisfied.

Anonymous said...

^^^ agree ... It would be interesting to see how "creative" the suits are.