Monday, June 24, 2019

Landing Gear Not Configured: Maule M-7-235B, N118G; Fatal accident occurred June 22, 2019 near Sunriver Airport (S21), Deschutes County, Oregon

Kevin Dale Padrick


















Aviation Accident Final Report - National Transportation Safety Board 

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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Hillsboro, Oregon
Lycoming; Williamsport, Pennsylvania

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


https://registry.faa.gov/N118G

Location: Sunriver, Oregon 
Accident Number: WPR19FA178
Date & Time: June 22, 2019, 10:40 Local
Registration: N118G
Aircraft: Maule M7-235B 
Aircraft Damage: Substantial
Defining Event: Landing gear not configured 
Injuries: 1 Fatal, 1 Minor
Flight Conducted Under: Part 91: General aviation - Personal

Analysis

The pilot and passenger departed on a local flight in the amphibious airplane from a paved runway. The passenger described the airplane's rate of climb after takeoff as "slow" and stated that it was apparent that the airplane would not clear the 50-ft-tall trees ahead. A witness described the airplane as "struggling to gain altitude" and noticed a "definite power loss." The pilot performed a forced landing to a river, where the airplane immediately nosed over and began filling with water. The landing gear was found in the extended position and the water rudders were retracted. The landing gear position indicators were operational and also indicated that the landing gear was extended. The position of the landing gear likely resulted in the airplane nosing over upon impact with the water.

Examination of the engine revealed that the muffler baffles had broken at the weld point. The left muffler baffling moved freely inside of the muffler. The right muffler baffling was turned 180° and was obstructing the exhaust outlet. A test run of the engine with the mufflers installed was unsuccessful; however, upon removal of the mufflers, the engine performed with no anomalies. There is no
requirement to check the inside of a muffler during annual or 100-hour inspections to ensure that the baffling is intact. It could not be determined as to how long these mufflers had been in this condition. It is likely that the airflow restriction of the separated baffling resulted in a partial loss of engine power and the airplane's subsequent inability to climb after takeoff. 

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 separation of baffling in both mufflers. Contributing to the accident was the pilot's failure to retract the landing gear on the float-equipped airplane before performing a forced landing to the river.

Findings

Aircraft (general) - Damaged/degraded
Personnel issues Forgotten action/omission - Pilot
Aircraft Wheel/ski/float - Incorrect use/operation
Environmental issues Water - Contributed to outcome

Factual Information

History of Flight

Initial climb Loss of engine power (partial)
Emergency descent Landing gear not configured (Defining event)
Landing Nose over/nose down

On June 22, 2019, about 1040 Pacific daylight time, an amphibious Maule M-7-235B airplane, N118G, was substantially damaged when it was involved in an accident near Sunriver, Oregon. The pilot was fatally injured, and the pilot-rated passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.

According to the passenger, the purpose of the flight was to see how the airplane performed with two people onboard. The pilot taxied the airplane to the runway, performed an engine run-up with no anomalies noted, and began the takeoff roll. The passenger stated that the throttle was full forward and the engine did not sound abnormal. He stated that the pilot rotated the airplane about 65 knots with about 1,000 ft of the 5,461-ft-long runway remaining, and the airplane lifted off the runway into ground effect. He recalled that once the airplane climbed out of ground effect, the rate of climb was slow, and it was apparent that they would not clear the 50-ft-tall trees across the river. The pilot maneuvered the airplane to the left, and the airplane touched down on the Deschutes River, nosed over, and began to fill with water. The passenger said that he was unaware that the river was the intended forced landing site until seconds before touchdown.

Two witnesses who saw the takeoff described the airplane as low and struggling to gain altitude. One witness stated that the engine "sounded like the pilot had not throttled up enough or the engine was bogging for some reason." He stated that there was a "definite power loss" but no "engine sputter or misfire." The airplane turned slowly to the left, continued losing altitude, and cleared large trees lining the Deschutes River. The witness then heard a loud pop, saw the splash, and the tail "flip over." Another witness said that the airplane impacted the tops of the trees.

Pilot Information

Certificate: Airline transport; Commercial; Flight instructor
Age: 63,Male
Airplane Rating(s): Single-engine land; Single-engine sea; Multi-engine land
Seat Occupied: Left
Other Aircraft Rating(s): Glider; Helicopter
Restraint Used: 3-point
Instrument Rating(s): Airplane; Helicopter
Second Pilot Present: Yes
Instructor Rating(s): Airplane multi-engine; Airplane single-engine; Glider; Helicopter; Instrument airplane; Instrument helicopter
Toxicology Performed: Yes
Medical Certification: Class 3 With waivers/limitations
Last FAA Medical Exam: March 7, 2019
Occupational Pilot: No
Last Flight Review or Equivalent: June 8, 2008
Flight Time: (Estimated) 7080 hours (Total, all aircraft), 73 hours (Total, this make and model), 15 hours (Last 90 days, all aircraft), 10 hours (Last 30 days, all aircraft)

Pilot-rated passenger Information

Certificate: Commercial 
Age: 69,Male
Airplane Rating(s): Single-engine land; Multi-engine land
Seat Occupied: Right
Other Aircraft Rating(s): 
Restraint Used: 3-point
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): Airplane multi-engine; Airplane single-engine; Instrument airplane
Toxicology Performed: No
Medical Certification: Class 2 Without waivers/limitations
Last FAA Medical Exam: March 7, 2019
Occupational Pilot: No 
Last Flight Review or Equivalent: March 15, 2019
Flight Time: 1600 hours (Total, all aircraft), 155 hours (Total, this make and model), 25 hours (Last 90 days, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: Maule 
Registration: N118G
Model/Series: M7-235B 
Aircraft Category: Airplane
Year of Manufacture: 1996
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 23025C
Landing Gear Type: Amphibian 
Seats: 4
Date/Type of Last Inspection: December 7, 2018 Annual
Certified Max Gross Wt.:
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 953.7 Hrs as of last inspection
Engine Manufacturer: Lycoming
ELT: 
Engine Model/Series: IO-540-W1A5
Registered Owner:
Rated Power: 235 Horsepower
Operator: On file 
Operating Certificate(s) Held: None

The last maintenance performed was dated June 4, 2019, at a tachometer time of 967.7 hours. The exhaust system was sent for repairs during an annual inspection on June 22, 2011, at an airframe total
time of 794.7 hours.

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual (VMC)
Condition of Light: Day
Observation Facility, Elevation: KBDN,3462 ft msl 
Distance from Accident Site: 18 Nautical Miles
Observation Time: 02:35 Local 
Direction from Accident Site: 38°
Lowest Cloud Condition: Clear 
Visibility 10 miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 6 knots / 
Turbulence Type Forecast/Actual: None / None
Wind Direction: 360° 
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 30.12 inches 
Hg Temperature/Dew Point: 16°C / 3°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Sunriver, OR (S21) 
Type of Flight Plan Filed: None
Destination: Sunriver, OR (S21)
Type of Clearance: None
Departure Time: 10:39 Local
Type of Airspace: Class G

Airport Information

Airport: SUNRIVER S21 
Runway Surface Type: Asphalt
Airport Elevation: 4163 ft msl 
Runway Surface Condition:
Runway Used: 18 
IFR Approach: None
Runway Length/Width: 5461 ft / 75 ft
VFR Approach/Landing: Forced landing

Wreckage and Impact Information

Crew Injuries: 1 Fatal, 1 Minor
Aircraft Damage: Substantial
Passenger Injuries:
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal, 1 Minor 
Latitude, Longitude: 43.864444,-121.455001(est)

The landing gear was found in the extended position. The water rudders were found in the retracted position. The pontoons (floats) were equipped with four visual landing gear position indicators. Each indicator was operational and indicated that the wheels were extended. Supplement 2 of the Maule Airplane Flight Manual stated, "Do not land on water unless the landing gear is fully retracted."
The engine was examined following recovery from the river. During the first attempt to run the engine, the engine started but would not maintain power. Examination of the mufflers revealed that the baffles had broken off at the weld point. The left muffler baffling moved freely inside of the muffler. The right muffler baffling was turned 180° and obstructed the outlet port.
Both mufflers were removed, and the engine was restarted; the throttle was advanced to about 1,500 rpm. A magneto drop was conducted. A loss of about 100 rpm was noted when the magnetos were
isolated. Power was then advanced to 2,400 rpm with no anomalies noted.

Per the maintenance manual TLC-M-7-235A/B, rev. C, dated April 13, 2016, and Part 43, Appendix D, there is no requirement to check the inside of a muffler during annual or 100-hour inspections to ensure that the baffling is intact. How long the mufflers had been in this condition on the accident engine could not be determined.

Medical and Pathological Information

An autopsy was performed by the Deschutes County Medical Examiner's Office. According to its report, the cause of death was drowning.

A toxicology screen performed by FAA's Forensic Sciences laboratory detected no carboxyhemoglobin or ethanol in blood. Rosuvastatin was detected in blood and liver tissue; rosuvastatin is not impairing.

Moments before a seaplane crashed upside down in the Deschutes River in June 2019, witnesses saw the plane struggling to gain altitude and then brush 50-foot-tall trees lining the river, according to the final crash report from the National Transportation Safety Board.

Safety board investigators determined the cause of the fatal crash was due to the plane losing engine power and the pilot’s failure to retract the landing gear, which caused the plane to flip upside down as it hit the water.

The pilot, Kevin Padrick, 63, of Sunriver, attempted to take off June 22, 2019, from the Sunriver Airport in his Maule M-7-235B but immediately felt the plane unable to reach altitude. Padrick, who had a passenger on board, banked the plane to the left to make an emergency landing in the river, according to the report. He told his passenger, “Oh, this looks bad.”

Padrick was killed in the crash. His passenger, Johannes Noordwijk, 69, of Sunriver, escaped the aircraft and suffered minor injuries. The plane had floated downstream about 300 feet, according to the report. It was removed from the river five days later.

Noordwijk told a safety board investigator the purpose of the flight was to see how the plane performed with two people on board. Padrick had just equipped the plane with floats a few weeks prior.

“Kevin was a very good pilot, but we didn't recognize the loss in power as we had no experience with the Maule on floats,” Noordwijk told the investigator. “If the Maule had been on wheels I am sure we had recognized it.”

Noordwijk said the takeoff felt slow because the floats are big and heavy. He estimates the entire flight lasted 16 seconds but it takes about 20 seconds to retract the wheels.

Noordwijk was unaware the river was Padrick’s intended forced landing site until seconds before they touched down in the water, he told the investigator.

Four bystanders jumped into the river to try to help Padrick and Noordwijk, but were unable to reach the plane. One bystander told Sunriver Police he swam to the plane, but the water was too cold and the current was too strong.

Sunriver Fire and Rescue personnel assisted the bystanders and Noordwijk to shore. Padrick’s body was later recovered by Deschutes County Sheriff’s Office search and rescue divers.

Two witnesses who saw the takeoff said the plane was flying noticeably low, according to the report.

One witness said the engine "sounded like the pilot had not throttled up enough or the engine was bogging for some reason." He stated that there was a "definite power loss.”

The other witness saw the plane barely clear a large tree along the river, before it crashed into the river.

“I heard a loud pop, saw the splash and the tail flip over,” the witness told the investigator.

Padrick, a former attorney in Portland, lived in Sunriver for 20 years and worked remotely for Obsidian Finance Group, a financial advisory and investment firm in Lake Oswego. Friends remembered Padrick as a talented pilot who flew stunt planes, gliders and seaplanes.


Location: Sunriver, OR 
Accident Number: WPR19FA178
Date & Time: 06/22/2019, 1040 PDT
Registration: N118G
Aircraft: Maule M7-235B
Injuries: 1 Fatal, 1 Minor
Flight Conducted Under: Part 91: General Aviation - Personal 

On June 22, 2019, about 1040 Pacific daylight time, a Maule M-7-235B, amphibian float equipped airplane, N118G, was substantially damaged when it nosed over during a forced water landing on Deschutes River near Sunriver, Oregon. The airline transport pilot was fatally injured, and the passenger sustained minor injuries. The airplane was registered to K2 Enterprises LLC. and operated by the pilot as a Title 14 Code of Federal Regulations part 91 personal flight. Visual meteorological conditions prevailed at the accident site about the time of the accident and no flight plan was filed for the local flight. The flight originated from Sunriver Airport (S21) Sunriver, Oregon about 1039.

According to the pilot rated passenger, the purpose of the flight was to see how the airplane performed with two persons onboard. The pilot taxied to runway 18, a 5,461 ft long and 75 ft wide asphalt runway, performed an engine run-up with no anomalies noted, and began his takeoff roll. The passenger stated that the throttle was full forward and the engine did not sound abnormal.

The passenger further reported that the pilot rotated about 65 knots with about 1,000 ft of runway remaining, and the airplane lifted off the runway, into ground effect. He recalled that once the airplane came out of ground effect, the rate of climb was slow, and it was apparent that they would not clear the 50 ft trees across the river. The pilot maneuvered the airplane to the left. At some point, the pilot stated, "oh this looks bad". The passenger recalled that he was unaware that the river was the intended forced landing site until seconds prior to touchdown. During the landing touchdown onto the river, the airplane nosed over, turned 180° and floated downstream about 300 ft.

Multiple witnesses reported that the airplane appeared to have difficulty gaining altitude during takeoff.

The airplane was recovered to a secure facility for further investigation.

Aircraft and Owner/Operator Information

Aircraft Make: Maule
Registration: N118G
Model/Series: M7-235B
Aircraft Category: Airplane
Amateur Built: No
Operator: K2 Enterprises LLC.
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KBDN, 3462 ft msl
Observation Time: 0235 UTC
Distance from Accident Site: 18 Nautical Miles
Temperature/Dew Point: 16°C / 3°C
Lowest Cloud Condition: Clear
Wind Speed/Gusts, Direction: 6 knots / , 360°
Lowest Ceiling: None
Visibility:  10 Miles
Altimeter Setting: 30.13 inches Hg
Type of Flight Plan Filed: None
Departure Point: Sunriver, OR (S21)
Destination: Sunriver, OR (S21)

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries: 1 Minor
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal, 1 Minor
Latitude, Longitude: 43.864444, -121.455000 (est)
 

Kevin D. Padrick

Mr. Padrick was an avid pilot:
Repairman - Experimental Aircraft Builder 
Pilot: Airline Transport - Airplane Multiengine Land 
Pilot: Commercial - Airplane Single Engine Land 
Pilot: Commercial - Rotorcraft-Helicopter 
Pilot: Commercial - Instrument Helicopter
Pilot: Commercial - Glider
Flight Instructor - Airplane Single And Multiengine
Flight Instructor - Rotorcraft-Helicopter
Flight Instructor - Instrument Airplane And Helicopter 
Flight Instructor - Glider

Mr. Kevin Dale Padrick holds an M.B.A., a J.D., and a B.S. in both mathematics and psychology, all awarded with honors. His four degrees were obtained over six years, the first two of which were spent at the United States Air Force Academy and the last four at the University of Santa Clara. 


 
Officials identified the pilot who died in a fatal plane crash Saturday in Sunriver as Kevin Padrick, 63, a co-founder of Lake Oswego-based Obsidian Financial Group.

Padrick worked in the Portland law firm Miller Nash Graham & Dunn, then called Miller Nash LLP, from 1979 to around 1993 or 1994, David Hercher, Padrick’s former coworker in the firm, said Sunday.

Hercher, now a federal judge in the United States bankruptcy court in Portland, called Padrick, “One of the smartest people I ever knew.”

“He was very giving and friendly to everybody,” Hercher said of his former mentor. “He was a great leader in the law firm. He inspired people to do their best.”

Hercher said Padrick’s leadership extended beyond the firm, calling him a “very inspiring as a leader in the Bar Association,” and adding he was an Eagle Scout who remained active in the Boy Scouts.

Padrick was a licensed pilot and flight instructor who lived in Sunriver.

“He was a pilot as long as I knew him,” Hercher said. “He was one of the most careful people I can imagine.”

In April of this year, Padrick was scheduled to speak to Columbia Aviation Association in advance of a trip to have amphibious floats installed on his Maule aircraft.

Officials identified the craft involved in the crash as a Maule M-7-235B with floats.

Padrick’s passenger, Johannes Noordwijk, 69, also of Sunriver, survived the crash. The Deschutes County Sheriff’s Office said in a news release Sunday that Noordwijk was able to escape after the aircraft crashed into the the Deschutes River and was helped to shore by Sunriver Fire and Rescue.

Padrick’s body was located later by Deschutes County Sheriff’s Office Search and Rescue divers, officials said.

Police said Saturday that they were notified of the crash at 10:42 a.m. when it was reported by a witness.

A picture posted to the Sunriver Fire and Rescue Instagram account Saturday showed a plane with pontoons upside down in the Deschutes River.

Ian Gregor, a spokesperson for the Federal Aviation Administration, said Saturday that the plane took off from Sunriver Airport said and that the pilot attempted to land on the Deschutes River “for unknown reasons.”

Gregor said the plane sank after landing.

Police are asking anyone who witnessed the incident or has video is to contact the Deschutes County Sheriff’s Office at 541-693-6911.

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




Deschutes County Sheriff's Office 

On 06-22-19 at approximately 10:40 am, Deschutes County 911 received a call of a plane crash in the Deschutes River near Sunriver. The plane flipped onto its top and submerged. Deschutes County Sheriff's Office (Patrol, Search and Rescue, and Marine Patrol), Sunriver Police Department, Oregon State Police and Sunriver Fire and Rescue responded.

Sunriver Fire and Rescue arrived and was able to rescue five (5) subjects from the aircraft as it floated upside down. One (1) of the subjects rescued was a male occupant of the aircraft who was able to escape the aircraft. The other subjects had swam to the plane to assist the occupants. It was determined a male subject was still underwater and initial rescue efforts were unsuccessful. The remaining occupant in the airplane was believed to be deceased.

The surviving occupant was transported to St. Charles Medical Center in Bend with injuries that are believed to be non-life threatening.

Deschutes County Sheriff's Office Search and Rescue with swift water rescue technicians and rescue divers arrived. While being supported by Marine Patrol Deputies, divers were able to locate the second occupant of the aircraft deceased underwater.

Initial information indicates the plane had just taken off from Sunriver Airport. The aircraft, an amphibious float plane, flipped upside down upon contact with the water. The crash is still under investigation by the National Transportation Safety Board. Any further information relating to the details of the crash investigation will be released by National Transportation Safety Board. The release of names of the occupants is pending notification of next of kin.

The Sheriff's Office was assisted at the scene by Sunriver Police and Fire, Oregon State Police and the Deschutes County Medical Examiner's Office.

7 comments:

  1. Looks like he had the wheels down for a hard surface landing when they should have been up for a water landing. This seems to happen often with floatplanes.

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  2. No investigation needed, picture says it all. Somebody needs to come up with a mod for water landing with wheels down or a spring loaded safety feature that retracts wheels when floats hit water.

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  3. ^^^^
    It's called having so much experience that you no longer need a checklist.
    SMDH!!!

    ReplyDelete
  4. ^^^ Right!
    Memory loss can begin from age 43. Mr. Padrick was age 63, he definitely should have had that checklist in his shirt pocket or very close at hand.

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  5. Sad that such an simple checklist item was missed and cost a life . No matter how much experience one might acquire , its the simple things that can turn disastrous. Condolences to his family and friends .

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  6. Padrick was an excellent and conscientious pilot who ALWAYS, ALWAYS, went through his checklist. He was diligent from the moment he got on the plane to when he got off, always being alert and prepared to respond. He didn't skip anything and was meticulous in everything he did. Safety was always his primary concern. His mind was clear and sharp, and if there was anything that he could have done to prevent what happened, he would have done it. There was clearly something wrong with the plane, not the pilot. For people to judge and jump to conclusions and insinuate that Padrick didn't do everything he should have, is a pretty low blow.

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  7. It says the total flight time was estimated at 16 seconds and it takes over 20 seconds to retract the wheels. Assume perhaps half the 16 seconds (8 sec) passed before he diagnosed the problem enough to begin wheel retraction... not enough time.

    ReplyDelete