Saturday, June 15, 2019

Loss of Control in Flight: Piper PA-30 Twin Comanche, N22HW, fatal accident occurred July 31, 2017 at Philip Billard Municipal Airport (KTOP), Topeka, Shawnee County, Kansas

Dr. William “Bill” Leeds - Pilot Receiving Instruction
Bill was a lifelong learner. He enjoyed flying, fishing with his wife and brother, spending time with the family pets, and damaging his home with tools, which he had no earthly idea how to use. 

James Kevin Bergman - Flight Instructor
Kevin was an avid pilot and loved traveling, flying and spending time with his children and family. He was a leading member of the KC Adventure Group and the flight club, Four Men and a Plane.

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

Additional Participating Entities:

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

Aviation Accident Factual Report - National Transportation Safety Board: 

Location: Topeka, KS
Accident Number: CEN17FA297
Date & Time: 07/31/2017, 2030 CDT
Registration: N22HW
Aircraft: PIPER PA30
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight
Injuries: 2 Fatal
Flight Conducted Under:  Part 91: General Aviation - Instructional

On July 31, 2017, about 2030 central daylight time, a Piper PA-30 airplane, N22HW, impacted terrain at Philip Billard Municipal Airport (TOP), Topeka, Kansas. The private pilot receiving instruction and the flight instructor sustained fatal injuries. The airplane was destroyed by impact forces. The airplane was privately owned and was being operated by the private pilot as a Title 14 Code of Federal Regulations Part 91 instructional flight. Day visual meteorological conditions prevailed at the time of the accident and no flight plan was filed for the local flight, which originated from TOP.

The pilot had been receiving instruction from the flight instructor in order to obtain an airplane multiengine land rating. The pilot's practical test (checkride) was scheduled for the next day, and the accident flight was a practice checkride.

A witness stated that the pilot and flight instructor arrived separately at the TOP fixed base operator lobby about 1920. The pilot and flight instructor discussed the training flight and the airplane logbooks before departing for the hangar where the airplane was kept. The witness then heard the pilots make a radio transmission that the airplane was taxiing to runway 18 for takeoff. He subsequently saw the airplane pass the terminal building during the accident takeoff "very low and not climbing very fast." The airplane then turned left and appeared to conduct a normal traffic pattern. He did not witness the accident.

A plot of engine parameters from the accident flight revealed left and right engine fuel flows that were approximately equivalent until about 7 minutes before the end of the recording, when the right engine fuel flow decreased from about 15 gallons per hour (gph) to about 3 gph. About 2.5 minutes before the end of the recording, the left engine fuel flow decreased to about 3 gph. About 1 minute before the end of the recording, both engine fuel flows increased to about 15 gph.

The airplane came to rest near the approach end of runway 13 at TOP, west of the runway 18 threshold. 

Student Pilot Information

Certificate: Private
Age: 61, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present:Yes 
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: BasicMed
Last FAA Medical Exam: 07/12/2017
Occupational Pilot: No
Last Flight Review or Equivalent: 05/08/2016
Flight Time: 945 hours (Total, all aircraft)

Flight Instructor Information

Certificate: Flight Instructor; Commercial
Age: 55, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s):None 
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s):
Toxicology Performed: Yes
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 07/02/2015
Occupational Pilot: Yes
Last Flight Review or Equivalent: 03/18/2017
Flight Time:  1386 hours (Total, all aircraft), 1281 hours (Pilot In Command, all aircraft)

Pilot Receiving Instruction

The pilot, age 61, reported 750 total hours of flight experience on the application for his most recent Federal Aviation Administration (FAA) third-class medical certificate, which was issued June 15, 2015, with a limitation that he have available glasses for near vision. He did not report using any medications. This medical certificate expired for all classes on June 30, 2017. The pilot had completed the BasicMed education and certification process; however, the pilot was a physician and had filled out the physician attestation and had his registered nurse sign the form.

Review of the pilot's logbook indicated that the pilot's first training flight in the accident airplane with the accident flight instructor occurred on May 13, 2017. The last two flights were dated July 9 and July 10, 2017, in the accident airplane with the accident flight instructor and were annotated in the logbook as "multiengine test prep." The logbook contained an entry by the flight instructor dated July 10 stating that the pilot received the required training for an airplane multiengine land rating and was prepared for an airplane multiengine land practical test.

Flight Instructor

The flight instructor, age 55, was issued an FAA third class medical certificate on July 2, 2015, with a limitation that he wear corrective lenses. He had reported having hypertension since 2010 and at his last exam reported the use of hydrochlorothiazide and captopril to treat it. Neither of these two blood pressure medications are considered impairing.

The flight instructor who provided the accident flight instructor's most recent flight review stated that the accident flight instructor performed well during the flight but seemed to display some complacency toward reference airspeeds and that his landing approach was unstable and flown at too high an airspeed. The instructor stated that he warned him about such an attitude and told him he wanted to see improvement on an instrument proficiency check that was planned for a later date. The instructor believed he saw improvement on the subsequent instrument proficiency check. 

Aircraft and Owner/Operator Information

Aircraft Make: PIPER
Registration: N22HW
Model/Series: PA30
Aircraft Category: Airplane
Year of Manufacture:1965 
Amateur Built: Yes
Airworthiness Certificate: Normal
Serial Number: 30-791
Landing Gear Type: Retractable - Tricycle
Seats: 4
Date/Type of Last Inspection: 08/26/2016, Annual
Certified Max Gross Wt.: 3600 lbs
Time Since Last Inspection: 95 Hours
Engines: 2 Reciprocating
Airframe Total Time: 5506.71 Hours at time of accident
Engine Manufacturer: Lycoming
ELT: Installed, not activated
Engine Model/Series: IO-320-B1A
Registered Owner: Individual
Rated Power: 160 hp
Operator: Individual
Operating Certificate(s) Held: None

The most recent annual inspection of the airplane and engines, dated August 26, 2016, occurred at an aircraft total time of 5,411.3 hours and a Hobbs time of 642.2 hours. The Hobbs meter at the accident site indicated 737.61 hours.

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light:Day 
Observation Facility, Elevation: TOP, 881 ft msl
Distance from Accident Site: 0 Nautical Miles
Observation Time: 1953 CDT
Direction from Accident Site:
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: Overcast / 10000 ft agl
Visibility (RVR):
Wind Speed/Gusts: Calm /
Turbulence Type Forecast/Actual: None / None
Wind Direction:
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 30.11 inches Hg
Temperature/Dew Point: 24°C / 18°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Topeka, KS (TOP)
Type of Flight Plan Filed: None
Destination: Topeka, KS (TOP)
Type of Clearance: VFR
Departure Time:  CDT
Type of Airspace:

Airport Information

Airport: Philip Billard Municipal Airport (TOP)
Runway Surface Type: Asphalt
Airport Elevation: 881 ft
Runway Surface Condition:
Runway Used: 18
IFR Approach: None
Runway Length/Width: 4331 ft / 75 ft
VFR Approach/Landing:

Wreckage and Impact Information

Crew Injuries: 2 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Fatal
Latitude, Longitude:  39.068611, -95.622500 (est) 

The wreckage was located between runway 13 and taxiway B on a magnetic heading about 125°. The airplane's wing flaps and landing gear were retracted. The left wing exhibited greater relative impact damage than the right wing and leading-edge crushing was consistent with a low-speed impact in a left wing-low and shallow pitch attitude.

The left and right propellers remained attached and secured to their respective crankshaft flanges. Both propellers displayed S-bending and leading-edge polishing consistent with torsion.

The left and right wings were attached and secure to the wing center section and fuselage. The left and right wings, empennage, and their respective control surfaces were attached and secure. Examination of the flight control system confirmed flight control continuity from the ailerons, stabilator, and rudder to their respective cockpit controls. Control continuity from the aileron and stabilator trim tabs was confirmed to the cockpit controls. The stabilator trim and rudder trim jack screws were in neutral positions.

There was no evidence of fire or soot on the wreckage and at the accident site.

An odor consistent with aviation fuel was present at the accident site and fuel drained from the wreckage during the airplane's recovery. Fuel was present in the fuel system. The fuel system was not obstructed by debris and testing of fuel within the system was negative for water.

The cockpit throttle, mixture, and propeller controls were in the forward position. Throttle and mixture control continuity was confirmed for both engines. Both fuel selectors were in the MAIN position.

Ignition timing of the left engine left and right magnetos were both 24° before top center (BTC). The right engine left magneto timing was 24° BTC and the right magneto timing was 25° BTC. The engines' data plate specifications for timing listed 25° BTC. The left and right engine magnetos produced an electrical spark through each lead in correct sequence when their magneto drive shafts were rotated through by hand.

Both engines' top spark plugs displayed features consistent with normal combustion.

The left engine was rotated using the vacuum pump accessory drive gear, and the right engine was rotated using the propeller. Both engine drive and valve train continuity to the accessory section was confirmed.

The propeller governor screens of both engines were free of debris.

Postaccident examination of the airplane revealed no mechanical anomalies that would have precluded normal operation. 

Medical And Pathological Information

Pilot Receiving Instruction

According to the autopsy performed at the request of the Shawnee County Coroner, Topeka, Kansas, the cause of death was blunt force injuries. Significant coronary artery disease with up to 80% stenosis of the left anterior descending, 50% stenosis of the left circumflex, and 20% stenosis of the right coronary arteries was noted; however, the remainder of the cardiac examination was unremarkable and there was no evidence of previous ischemia or scar.

Toxicology testing for drugs of abuse by Axis Forensic Laboratory at the request of the coroner was negative. Toxicology testing performed at the FAA Forensic Sciences Laboratory identified citalopram, its metabolite N-desmethylcitalopram, and metoprolol in cavity blood and urine.

Citalopram is an antidepressant. While it is not generally considered impairing, the underlying depression can cause significant cognitive impairment. As a result, the FAA requires pilots with depression who require treatment with medication to ensure their depression is adequately treated and have their cognition evaluated before a medical certificate is issued. Metoprolol is a blood pressure medication that can also lower the risk of recurrent heart attack for patients who have already had one heart attack; it is not generally considered impairing.

Flight Instructor

According to the autopsy performed at the request of the Shawnee County Coroner, Topeka, Kansas, the cause of death was blunt force injuries. No significant natural disease was identified.

Toxicology testing for drugs of abuse by Axis Forensic Laboratory at the request of the coroner was negative. Toxicology testing performed at the FAA Forensic Sciences Laboratory did not identify any tested-for drugs. 

Additional Information

The airplane was equipped with a J.P. Instruments EDM-760, which was a panel-mounted gauge that allowed for the monitoring and recording of up to 24 parameters related to engine operations. The EDM-760 was downloaded by the National Transportation Safety Board Vehicle Recorder Division.

A plot of engine parameters from the accident flight beginning of the recording showed a left and right engine fuel flows that were approximately equivalent until about 7 minutes prior to the end of the recording when the left and right engine had fuel flows of about 15 gallons per hour (GPH) and the right engine fuel flow decrease to about 3 gallons per hour. About 2 ½ minutes prior to the end of the recording, the left engine fuel flow decreased to about 3 GPH. About 1 minute prior to the end of the recording both engine fuel flows increase to about 15 GPH. There were corresponding changes in fuel flow in left and right engine cylinder head temperatures.

An employee of the pilot's business stated that the pilot had "expressed a lot of frustration" in the previous weeks about his multiengine airplane training. The pilot told her that during flight training, the flight instructor had him practice a lot of "engine stalls," and if the engine stalls and you don't react quick enough, then you "end up in a spiral." She thought that the pilot was interested in purchasing the accident airplane, but she did not know what the arrangement was for its use was between the pilot and the airplane owner.

A friend of the student pilot and accident flight instructor stated that the pilot was probably the accident flight instructor's first multiengine student. He stated that the pilot had begun to complain to him that the flight instructor took too many risks and made him nervous, particularly with single-engine work during the training. The pilot was upset that the flight instructor would not sign him off for the checkride, and the flight instructor wanted one more simulated checkride before the actual checkride.

The friend stated that the pilot told him he would take the one more training session with the accident flight instructor and then he would never have to fly with him again.

1 comment:

Anonymous said...

I guess the takeaway from this accident is to follow your first instinct when it comes to pilot-instructor chemistry. The accident instructor had known issues with flying by the numbers, and apparently took chances in his lesson technique. Some people simply don't make good teachers.