Monday, May 27, 2019

Loss of Control in Flight: Belair Raven, C-FNKZ, fatal accident occurred May 05, 2018 at Sault Ste. Marie Municipal Airport (KANJ), Chippewa County, Michigan

Gilbert Origene Belair
Pilot


Jean-Paul Finck
Pilot-Rated Passenger 


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

Additional Participating Entity:

Federal Aviation Administration / Flight Standards District Office; Grand Rapids, Michigan

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


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


http://wwwapps.tc.gc.ca




Location: Sault Ste Marie, MI
Accident Number: CEN18FA160
Date & Time: 05/05/2018, 1002 EDT
Registration: C-FNKZ
Aircraft: BELAIR RAVEN
Aircraft Damage: Substantial
Defining Event: Loss of control in flight
Injuries: 2 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal

Analysis 

The private pilot and pilot-rated passenger were departing on a local flight in the experimental, amateur-built airplane in gusting crosswind conditions. Witnesses saw the airplane take off and enter a nose-high attitude. About 100 ft above ground level, the airplane began turning right and transitioned to a nose-low spin until ground impact. Examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The airplane was not equipped with any stall warning devices.

The witness reports and damage to the airplane were consistent with the pilot failing to maintain sufficient airspeed during a steep takeoff climb, which resulted in the airplane exceeding its critical angle of attack and a subsequent aerodynamic stall. A flight instructor at the airport reported that, when departing the accident runway with westerly winds present, he would often notice turbulence and swirling air. He attributed this effect to the tall trees located about 100 yards west of the runway. Although autopsies revealed that both pilots were at risk for a sudden cardiac event, the circumstances of the accident are consistent with a loss of control rather than a sudden incapacitation, and it is unlikely that either pilot's cardiac condition contributed to the accident. 

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 adequate airspeed during takeoff in gusty crosswind conditions, which resulted in the airplane exceeding its critical angle of attack and an aerodynamic stall. 

Findings

Aircraft
Airspeed - Not attained/maintained (Cause)
Angle of attack - Capability exceeded (Cause)

Personnel issues
Aircraft control - Pilot (Cause)

Environmental issues
Gusts - Effect on equipment

Factual Information

History of Flight

Takeoff
Loss of control in flight (Defining event)

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

On May 5, 2018, at 1002 eastern daylight time, an experimental, amateur-built Belair Raven airplane, Canadian registration C-FNKZ, impacted terrain during the initial climb after takeoff from Sault Ste. Marie Municipal Airport (ANJ), Sault Ste. Marie, Michigan. The private pilot and pilot-rated passenger were fatally injured, and the airplane was substantially damaged. The airplane was owned by the pilot who was operating it as a Title 14 Code of Federal Regulations Part 91 personal flight. Day, visual meteorological conditions prevailed for the local flight, which departed without a flight plan.


According to witnesses, the airplane taxied to runway 32 and departed in a nose-high attitude. A flight instructor compared the climb to an aggressive short-field takeoff or a banner pilot's climb after picking up a banner. Witnesses noticed that, after reaching about 100 ft above ground level, the airplane turned right and transitioned to a steep nose-down spin until ground impact. The flight instructor stated that the engine noise sounded normal throughout the takeoff until ground impact.

On May 5, 2018, at 1002 eastern daylight time, an experimental, amateur-built Belair Raven airplane, Canadian registration C-FNKZ, impacted terrain during the initial climb after takeoff from Sault Ste. Marie Municipal Airport (ANJ), Sault Ste. Marie, Michigan. The private pilot and pilot-rated passenger were fatally injured, and the airplane was substantially damaged. The airplane was owned by the pilot who was operating it as a Title 14 Code of Federal Regulations Part 91 personal flight. Day, visual meteorological conditions prevailed for the local flight, which departed without a flight plan.

According to witnesses, the airplane taxied to runway 32 and departed in a nose-high attitude. A flight instructor compared the climb to an aggressive short-field takeoff or a banner pilot's climb after picking up a banner. Witnesses noticed that, after reaching about 100 ft above ground level, the airplane turned right and transitioned to a steep nose-down spin until ground impact. The flight instructor stated that the engine noise sounded normal throughout the takeoff until ground impact.

Gilbert Origene Belair

Pilot Information

Certificate: Private
Age: 67, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 4-point
Instrument Rating(s): None
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 02/08/2018
Occupational Pilot: No
Last Flight Review or Equivalent: 
Flight Time:   505 hours (Total, all aircraft), 61 hours (Total, this make and model), 455 hours (Pilot In Command, all aircraft), 8 hours (Last 90 days, all aircraft), 2 hours (Last 30 days, all aircraft), 0 hours (Last 24 hours, all aircraft) 

Pilot-Rated Passenger Information

Certificate: Private
Age: 75, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s): None
Restraint Used: 4-point
Instrument Rating(s): None
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 1 With Waivers/Limitations
Last FAA Medical Exam: 01/24/2018
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time: 

The pilot, age 67, held a Canadian private pilot certificate with an airplane single-engine land rating. On February 8, 2018, the pilot was issued a Canadian Category 3 medical certificate with a requirement for glasses to be worn and a restriction of day visual only flight due to color vision deficiencies. The pilot had accumulated 505 total hours of flight experience, with 61 hours in the accident airplane. Flight reviews were not recorded in the pilot's logbook.

The pilot-rated passenger, age 75, held a Canadian private pilot certificate with an airplane single-engine land rating. On January 24, 2018, the passenger was issued a Canadian Category 1 medical certificate with a requirement for glasses to be worn. The passenger frequently flew with the pilot in the accident airplane. 



Aircraft and Owner/Operator Information

Aircraft Make: BELAIR
Registration: C-FNKZ
Model/Series: RAVEN
Aircraft Category: Airplane
Year of Manufacture: 2012
Amateur Built: Yes
Airworthiness Certificate: Experimental
Serial Number: 12351
Landing Gear Type: Tailwheel
Seats: 4
Date/Type of Last Inspection:
Certified Max Gross Wt.: 2400 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 61 Hours at time of accident
Engine Manufacturer: Honda
ELT: C91A installed, not activated
Engine Model/Series: 3.5 Litre
Registered Owner: On file
Rated Power: 245 hp
Operator: On file
Operating Certificate(s) Held: None

The high-wing, tailwheel-equipped airplane was completed by the pilot in 2012 and was issued a Canadian Special Certificate of Airworthiness. The airplane was equipped with a Honda 3.5-liter engine and a Performance three-blade, fixed pitch wooden propeller. The airplane was not equipped with any stall warning devices. On the day of the accident, the airplane was lightly loaded with cargo.




Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KANJ, 724 ft msl
Distance from Accident Site: 0 Nautical Miles
Observation Time: 0955 EDT
Direction from Accident Site: 70°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 11 knots / 15 knots
Turbulence Type Forecast/Actual: /
Wind Direction: 270°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 29.93 inches Hg
Temperature/Dew Point: 12°C / 3°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: SAULT STE MARIE, MI (ANJ)
Type of Flight Plan Filed: None
Destination: SAULT STE MARIE, MI (ANJ)
Type of Clearance: None
Departure Time: 1002 EDT
Type of Airspace: Class G 

At 0955, the automated weather observation station (AWOS) at ANJ reported wind from 270° at 11 knots with gusts to 15 knots, 10 miles visibility, clear skies, temperature 12°C, dew point 3°C, and an altimeter setting of 29.93 inches of mercury. The AWOS was located about 1/4 mile east of the runway.

Airport Information

Airport: SAULT STE MARIE MUNI/SANDERSON (ANJ)
Runway Surface Type: Asphalt
Airport Elevation: 716 ft
Runway Surface Condition: Dry
Runway Used: 32
IFR Approach: None
Runway Length/Width: 5234 ft / 100 ft
VFR Approach/Landing: None

ANJ was a public, non-towered airport owned by the City of Sault Saint Marie. The airport had one runway and surveyed elevation of 716 ft above mean sea level. Runway 14/32 was a 5,234 ft by 100 ft runway with an asphalt surface. 

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: 46.477500, -84.363056 

Examination at the accident site revealed that the airplane impacted terrain and came to rest in a near-vertical, nose-down attitude on a heading about 201° about 180 ft east of runway 32.

Both wings were crushed aft and remained attached to the fuselage. The fixed main landing gear assemblies were attached to the fuselage and the flight control surfaces remained attached to their respective airframe surfaces; elevator control, elevator trim, and rudder control continuity was established to the cockpit area. Aileron control continuity was established from both ailerons to the cockpit. The left aileron cable, which was slack, was disengaged from its respective bellcrank.

All three multilaminate wood propeller blades were fractured near the hub. The propeller remained attached to the engine and the spinner was crushed aft. The engine was rotated by hand from the front crankshaft. Thumb suction and compression was observed at all cylinders with normal valve train and crankshaft continuity. Spark plug electrodes exhibited normal wear signatures.

Witness marks on the seat rails indicated that both pilot and passenger seats were in a normal position during ground impact. Examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. 

Medical And Pathological Information

The Chippewa County Medical Examiner, Sault Ste. Marie, Michigan, conducted autopsies of the pilot and passenger and determined that the cause of their deaths was due to blunt force injuries.

The pilot's autopsy revealed left ventricular hypertrophy, a thickening of the wall of the left ventricle. The coronary arteries were free from atherosclerosis. An area of scar in the subepicardial area of the anterior wall of the left ventricle as well as some fibrosis in the lateral and posterior walls were identified with microscopy. The remainder of the cardiac examination was unremarkable. The pilot's wife stated that the pilot had experienced chest pains about 3 years before the accident, but she was not aware of any recent significant health issues.

The passenger's autopsy revealed evidence of bilateral corneal transplants and emphysema. An area of 70-80% stenosis was identified in the left anterior descending coronary artery and there was some evidence of perivascular fibrosis on the microscopic examination in the anterior and lateral walls, as well as the left side of the septum. The passenger's son stated that, during the 2 years before the accident, his father would get tired more easily during walks and while climbing stairs.

The Federal Aviation Administration Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, conducted toxicological testing on specimens from the pilot and passenger. The results were negative for all tests conducted.

Additional Information

According to the flight instructor who witnessed the accident, during departures from runway 32 with westerly winds present, he would often notice turbulence and swirling air. He attributed this effect to the tall trees located about 100 yards west of the runway.

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