Tuesday, October 1, 2019

Piper PA-22-150 Tri-Pacer, N6936B: Loss of Control in Flight, fatal accident occurred August 25, 2018 and Loss of Control on Ground, accident occurred July 05, 2017

Lt. Col. Mark C. Biron



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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Portland, Maine
Textron Lycoming; Williamsport, Pennsylvania
 
Aviation Accident Factual Report - National Transportation Safety Board: https://app.ntsb.gov/pdf


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


https://registry.faa.gov/N6936B



Location: Island Pond, VT
Accident Number: ERA18FA232
Date & Time: 08/25/2018, 1520 EDT
Registration: N6936B
Aircraft: Piper PA22
Aircraft Damage: Substantial
Defining Event: Loss of control in flight
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

On August 25, 2018, between 1505 and 1520 eastern daylight time, a Piper PA-22-150 airplane, N6936B, was destroyed when it collided with terrain while attempting to land at John H. Boylan State Airport (5B1), Island Pond, Vermont. The private pilot was fatally injured. The airplane was registered to the pilot who was operating it as a Title 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed, and no flight plan was filed for the local flight, which originated from 5B1 between 1445 and 1500.

According to a friend of the pilot, the purpose of the flight was to prepare for an upcoming flight review that was scheduled for later in the week. The pilot normally flew on Sunday afternoons and would typically remain in the local area.

A witness, who was also a pilot, was at his home when he heard the airplane depart between 1445 and 1500 and then return about 20 minutes later to land at 5B1. When he heard the airplane returning to the airport, he used his binoculars and confirmed the airplane belonged to his friend, who occupied the hangar next to him at the airport. The witness said that the airplane was on the left downwind leg for runway 32 at an altitude about 1,000 ft above ground level (agl). Everything seemed normal and the engine sounded fine. The witness recalled hearing the pilot "throttle back" as he entered the downwind and stated that the engine sounded "smooth." The witness lost sight of the airplane while it was still on the downwind leg of the traffic pattern and it was not until later in the afternoon that he learned the airplane had crashed on airport property.

A review of air traffic control (ATC) communications and radar data revealed that the pilot was not in contact with ATC and there were no radar returns for any aircraft flying in the vicinity of Island Pond around the time of the accident.

There were no witnesses to the accident and the actual time of the accident could not be determined. The pilot's wife obtained photos from a hunter who arrived on-scene after the accident. The photos were taken at 1532. 


Lt. Col. Mark C. Biron 

Pilot Information

Certificate: Private
Age: 60, Male
Airplane Rating(s): 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: Yes
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 06/21/2018
Occupational Pilot: No
Last Flight Review or Equivalent: 08/13/2016
Flight Time:  (Estimated) 1289.6 hours (Total, all aircraft), 362 hours (Total, this make and model), 1228 hours (Pilot In Command, all aircraft)

The pilot held a private pilot certificate with ratings for airplane single-engine land and instrument airplane. His most recent Federal Aviation Administration (FAA) third-class medical certificate was issued on June 21, 2018. A review of the pilot's logbook revealed that he had accrued about 1,289 total hours of flight experience, of which about 362 hours were in the accident airplane.

The pilot also held an airframe and powerplant mechanic certificate. 

Aircraft and Owner/Operator Information

Aircraft Make: Piper
Registration: N6936B
Model/Series: PA22 150
Aircraft Category: Airplane
Year of Manufacture:
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 22-4215
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection: 04/09/2018, Annual
Certified Max Gross Wt.: 2000 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 2661 Hours as of last inspection
Engine Manufacturer: Lycoming
ELT: C126 installed, not activated
Engine Model/Series: O-320 SERIES
Registered Owner: On file
Rated Power: 150 hp
Operator: On file
Operating Certificate(s) Held: None

The accident airplane, manufactured in 1956, was a single-engine, 4-seat, strut braced, high-wing, fabric-covered airplane. It was powered by a Lycoming O-320 series, 150-horsepower engine equipped with a two-bladed Sensenich propeller.

A review of the airplane's maintenance logbook revealed that the most recent annual inspection was conducted on April 9, 2018, at an airframe total time of 2,661.0 hours. The engine had accrued 168.65 since major overhaul as of the last annual. The inspection was conducted and signed off by the pilot.




Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KCDA, 1188 ft msl
Distance from Accident Site: 16 Nautical Miles
Observation Time: 1535 EDT
Direction from Accident Site: 211°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 8 knots /
Turbulence Type Forecast/Actual: None / None
Wind Direction: 120°
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 30.23 inches Hg
Temperature/Dew Point: 26°C / 14°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Island Pond, VT (5B1)
Type of Flight Plan Filed: None
Destination: Island Pond, VT (5B1)
Type of Clearance: None
Departure Time: 1500 EDT
Type of Airspace: Unknown

Weather reported at 1535 at Caledonia Airport (CDA), Caledonia, Vermont, about 16 miles southwest of the accident site, included wind from 120° at 8 knots, 10 miles visibility, and clear skies. The temperature was 79°F and the dew point was 57°F, with an altimeter setting of 30.23 inches of mercury.

The witness described the wind conditions as a southerly crosswind that was shifting about 10° left and right. He said that the wind conditions were such that the pilot could have landed on either runway. 

Airport Information

Airport: John H Boylan State (5B1)
Runway Surface Type: Grass/turf
Airport Elevation: 1194 ft
Runway Surface Condition: Dry; Vegetation
Runway Used: 32
IFR Approach: None
Runway Length/Width: 2650 ft / 120 ft
VFR Approach/Landing: Full Stop; Traffic Pattern

John H. Boylan State Airport was a publicly-owned, non-tower controlled airport in northern Vermont, about 16 miles south of the Canadian border. It was equipped with one turf runway, oriented 14/32, that measured 2,650 ft long and 120 ft wide. 




Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 44.790000, -71.826389 (est)

The airplane came to rest upright on airport property on a heading of 070° and sustained extensive postimpact fire damage. The location of the accident site was consistent with the airplane turning from the downwind leg to a left base leg of the airport traffic pattern. The initial impact point was a ground scar located about 10 ft forward of where the airplane came to rest. Several pieces of broken Plexiglas were found in the ground scar. Another ground scar extended about 13 ft to the right of the initial impact scar. Imbedded in the ground at the end of the scar was an unburned section of the airplane's right wing tip.

The leading edges of both wings exhibited extensive leading edge crushing and were pushed aft. The wing struts were buckled on both sides and the left and right flaps were consumed by fire. The manual flap handle was broken but the actuator was in the fully-extended position. The left and right wing fuel tanks were breached and partially consumed by fire. The auxiliary fuel tank was completely consumed by fire. The main landing gear was splayed and resting underneath the main wreckage. The tailwheel was undamaged and remained attached to the airframe.

All major flight controls were accounted for at the site and flight control continuity was established to the cockpit area; however, a fractured section of left aileron cable was submitted to the NTSB Materials Laboratory. The cable fracture was located about 15 inches from a looped end. The looped end was inserted through an eye at one end of a turnbuckle assembly. This assembly originally included a brass barrel adjuster. The barrel was missing, but the safety wire was still present. Examination of the turnbuckle threads indicated that pieces of brass material were still attached to the threads on a few locations. The threaded rod ends were examined for any indication of damage, but none was found. Examination of the cable fracture revealed the individual wire strands exhibited 45° shear planes, consistent with an overload fracture of the cable under a combination of shear and torsion loads. The rudder pedals were consumed by fire, but the T-posts on the left side were displaced to the left and the posts on the right were straight.

The cockpit area sustained extensive fire damage. Though several instruments and radios were located in the wreckage, damage precluded obtaining any useful information from them. The carburetor and mixture controls were not located; however, the throttle was in place and appeared to be toward the idle position. The fuel selector was found in the "ON" position.

The airplane was equipped with two front seats, which remained in place in the main wreckage. Only the frames remained. The airplane was equipped with shoulder harnesses. All seatbelt and shoulder harness mounting brackets were found secured to their respective attach points on the airframe structure. Both front seatbelt/shoulder harness buckles were found in the wreckage. Both male ends were securely seated in the female end of the buckles.

The airplane's windshield was made of Plexiglas, which shattered from impact. Examination of the recovered sections of Plexiglas revealed no evidence of a bird strike.

The engine sustained impact and fire damage and remained partially attached to the airplane; the two-bladed propeller remained attached to the engine. The propeller spinner was crushed up and inward, and the engine was pushed into the firewall and cockpit area. One blade exhibited slight s-bending and the other blade was bent slightly forward and displayed trailing-edge nicks and leading-edge polishing.

The top and bottom spark plugs were removed. All the electrodes were black and the Nos. 2 and 4 bottom spark plugs were oil-soaked.

Both magnetos remained partially attached to the engine but exhibited extensive fire damage and could not be tested. The left magneto sustained more fire damage than the right magneto. The ignition leads had burned away except for a few short sections that were still attached to the right magneto.

The vacuum pump was partially attached and exhibited impact and fire damage and could not be tested. The drum was broken but all vanes were intact.

The firewall fuel strainer bowl sustained impact and fire damage. The bowl exhibited some heat damage and the bowl was empty. The screen was not located.

The carburetor was removed and exhibited impact and fire damage. The finger screen was removed, and dirt was found inside the screen area. The carburetor was opened and the composite floats had melted. No fuel was in the bowl.

The engine was manually rotated via the propeller, and compression and valve train continuity were established for each cylinder. No pre-accident mechanical deficiencies were noted that would have precluded normal operation of the engine. 

Medical And Pathological Information

An autopsy was performed by the Office of the Chief Medical Examiner, State of Vermont, Burlington, Vermont. The cause of death was determined to be blunt trauma and thermal injuries.

Toxicology testing performed by the FAA's Forensic Sciences Laboratory identified ibuprofen and diphenhydramine in urine as well as ranitidine, diphenhydramine (too low to quantify), and atorvastatin in heart blood. Ibuprofen is an over-the-counter analgesic often marketed with the names Motrin or Advil. Ranitidine is an over-the-counter heartburn medication often marketed as Zantac. Atorvastatin is a prescription medication for high cholesterol. None of these are considered impairing. Diphenhydramine is a sedating antihistamine available over-the-counter in many products used to treat colds, allergies, and insomnia. Its most common other names are Benadryl and Unisom. Diphenhydramine undergoes postmortem distribution and central levels may be 3 times higher than peripheral levels.

Additional Information

A friend of the pilot, who had been a pilot for 58 years but no longer flew due to health reasons, said he flew with the pilot almost every Sunday. He described the pilot as being very thorough and always completing a preflight inspection. During the inspection, he would check the fuel for water "every time." Based on the previous weekend's flight, the airplane most likely contained a total of 18 gallons (9 gallons per wing fuel tank) when the pilot departed on the accident flight. Though the friend described the pilot as being conscientious, he said that the pilot tended to turn from the downwind leg onto the base leg of the traffic pattern "quite steep" (about 40° bank) and slow (62-63 knots). The friend shared his concern with the pilot, but the pilot did not seem to be concerned with stalling the airplane. The airplane was not equipped with a stall warning horn or angle-of-attack indicator. The friend also stated that it was normal for the pilot to turn to the base leg early and land about 800 ft from the approach end of the runway, which would allow him to bring the airplane to a stop in front of his hangar.


According to the Piper PA-22-150 Information Manual, the airplane's stall speed at gross weight in level flight with the flaps fully extended was 49 mph, or 42 knots.

Federal Aviation Administration / Flight Standards District Office; Portland, Maine

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Portland, Maine

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

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


Location: Berlin, NH
Accident Number: GAA17CA392 
Date & Time: 07/05/2017, 1255 EDT
Registration: N6936B
Aircraft: PIPER PA22
Aircraft Damage: Substantial
Defining Event: Loss of control on ground
Injuries: 1 None
Flight Conducted Under: Part 91: General Aviation - Personal

Analysis 

The pilot of the tailwheel-equipped airplane reported that, during the landing roll, the airplane veered to the left off the runway. He added that he applied full power and "managed to maneuver the plane out of the ground loop but started taking out runway lights" as he maneuvered the airplane back toward the runway. The airplane impacted a runway light and two taxiway signs, damaging the main landing gear. The airplane then "flew over the runway," landed, and the main landing gear collapsed.

The airplane sustained substantial damage to the fuselage and left wing lift struts.

The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.

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 directional control during the landing roll.

Findings

Aircraft
Directional control - Not attained/maintained (Cause)

Personnel issues
Aircraft control - Pilot (Cause)

Environmental issues
Runway/taxi/approach light - Contributed to outcome

Factual Information

History of Flight

Landing
Loss of control on ground (Defining event)

Landing-landing roll
Runway excursion
Attempted remediation/recovery
Collision with terr/obj (non-CFIT)
Landing gear collapse

Pilot Information

Certificate: Private
Age: 58, Male
Airplane Rating(s): 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 2 Waiver Time Limited Special
Last FAA Medical Exam: 06/06/2017
Occupational Pilot: No
Last Flight Review or Equivalent: 08/13/2016
Flight Time:  (Estimated) 1239 hours (Total, all aircraft), 346 hours (Total, this make and model), 1212 hours (Pilot In Command, all aircraft), 4 hours (Last 90 days, all aircraft), 3 hours (Last 30 days, all aircraft) 

Aircraft and Owner/Operator Information

Aircraft Make: PIPER
Registration: N6936B
Model/Series: PA22 150
Aircraft Category: Airplane
Year of Manufacture: 1957
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 22-4215
Landing Gear Type: Tailwheel
Seats: 4
Date/Type of Last Inspection: 12/01/2016, Annual
Certified Max Gross Wt.: 2000 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 2660 Hours at time of accident
Engine Manufacturer: LYCOMING
ELT: C126 installed, not activated
Engine Model/Series: O-320 SERIES
Registered Owner: On file
Rated Power: 150 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: KBML, 1158 ft msl
Distance from Accident Site: 0 Nautical Miles
Observation Time: 1652 UTC
Direction from Accident Site: 215°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: Light and Variable /
Turbulence Type Forecast/Actual: / None
Wind Direction: Variable
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 30.22 inches Hg
Temperature/Dew Point:  26°C / 6°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: ISLAND POND, VT (5B1)
Type of Flight Plan Filed: None
Destination: Berlin, NH (BML)
Type of Clearance: None
Departure Time: 1155 EDT
Type of Airspace: Class G 

Airport Information

Airport: BERLIN RGNL (BML)
Runway Surface Type: Asphalt
Airport Elevation: 1161 ft
Runway Surface Condition: Dry
Runway Used: 36
IFR Approach: None
Runway Length/Width: 5200 ft / 100 ft
VFR Approach/Landing: Full Stop 

Wreckage and Impact Information

Crew Injuries: 1 None
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 None
Latitude, Longitude:  44.577500, -71.177500 (est)

Preventing Similar Accidents  

Stay Centered: Preventing Loss of Control During Landing

Loss of control during landing is one of the leading causes of general aviation accidents and is often attributed to operational issues. Although most loss of control during landing accidents do not result in serious injuries, they typically require extensive airplane repairs and may involve potential damage to nearby objects such as fences, signs, and lighting.

Often, wind plays a role in these accidents. Landing in a crosswind presents challenges for pilots of all experience levels. Other wind conditions, such as gusting wind, tailwind, variable wind, or wind shifts, can also interfere with pilots’ abilities to land the airplane and maintain directional control.

What can pilots do?

Evaluate your mental and physical fitness before each flight using the Federal Aviation Administration’s (FAA) “I'M SAFE Checklist." Being emotionally and physically ready will help you stay alert and potentially avoid common and preventable loss of control during landing accidents.

Check wind conditions and forecasts often. Take time during every approach briefing to fully understand the wind conditions. Use simple rules of thumb to help (for example, if the wind direction is 30 degrees off the runway heading, the crosswind component will be half of the total wind velocity).

Know your limitations and those of the airplane you are flying. Stay current and practice landings on different runways and during various wind conditions. If possible, practice with a flight instructor on board who can provide useful feedback and techniques for maintaining and improving your landing procedures.

Prepare early to perform a go around if the approach is not stabilized and does not go as planned or if you do not feel comfortable with the landing. Once you are airborne and stable again, you can decide to attempt to land again, reassess your landing runway, or land at an alternate airport. Incorporate go-around procedures into your recurrent training.

During landing, stay aligned with the centerline. Any misalignment reduces the time available to react if an unexpected event such as a wind gust or a tire blowout occurs.

Do not allow the airplane to touch down in a drift or in a crab. For airplanes with tricycle landing gear, do not allow the nosewheel to touch down first.
Maintain positive control of the airplane throughout the landing and be alert for directional control difficulties immediately upon and after touchdown. A loss of directional control can lead to a nose-over or ground loop, which can cause the airplane to tip or lean enough for the wing tip to contact the ground.
Stay mentally focused throughout the landing roll and taxi. During landing, avoid distractions, such as conversations with passengers or setting radio frequencies.

Interested in More Information?

The FAA’s “Airplane Flying Handbook” (FAA-H-8083-3B), chapter 8, “Approaches and Landings,” provides guidance about how to conduct crosswind approaches and landings and discusses maximum safe crosswind velocities. The handbook can be accessed from the FAA’s website (www.faa.gov).

The FAA Safety Team (FAASTeam) provides access to online training courses, seminars, and webinars as part of the FAA’s “WINGS—Pilot Proficiency Program.” This program includes targeted flight training designed to help pilots develop the knowledge and skills needed to achieve flight proficiency and to assess and mitigate the risks associated with the most common causes of accidents, including loss of directional control. The courses listed below can be accessed from the FAASTeam website (www.faasafety.gov).

Avoiding Loss of Control
Maneuvering: Approach and Landing
Normal Approach and Landing
Takeoffs, Landings, and Aircraft Control

The Aircraft Owners and Pilots Association Air Safety Institute offers several interactive courses, presentations, publications, and other safety resources that can be accessed from its website (www.aopa.org/asf/).

The NTSB’s Aviation Information Resources web page, www.ntsb.gov/air, provides convenient access to NTSB aviation safety products.

The NTSB presents this information to prevent recurrence of similar accidents. Note that this should not be considered guidance from the regulator, nor does this supersede existing FAA Regulations (FARs).

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