Saturday, November 09, 2019

Loss of Control in Flight: Cessna 152, N24987; fatal accident occurred November 19, 2017 near Tehachapi Municipal Airport (KTSP), Kern County, California

Kelvin Arayon Javier
 Born on November 13, 1968, in Cavite City, Philippines, passed away November 19th, 2017. Kelvin resided in Cerritos, California, at the time of his passing.
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The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Van Nuys, California
Textron Aviation; Wichita, Kansas
Lycoming Engines; 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
 
http://registry.faa.gov/N24987


Location: Tehachapi, CA
Accident Number: WPR18FA035
Date & Time: 11/19/2017, 1756 PST
Registration: N24987
Aircraft: CESSNA 152
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

Analysis 

The private pilot departed on a personal flight in visual meteorological conditions during the early evening and flew to a nearby airport, where he parked the airplane and walked to a nearby restaurant. He returned to the airplane about an hour later, which was about 20 minutes after the end of civil twilight. Surveillance video captured the accident airplane depart the runway and enter a right traffic pattern, which was the opposite of the published left traffic pattern and took the airplane over unlit pasture and hills. The imagery then depicted the airplane enter a rapid descent on what appeared to be the right downwind leg of the traffic pattern. The airplane disappeared from view consistent with ground impact. The descent duration was about 7 seconds.

The airplane impacted a pasture north of the airport. The debris field indicated that the airplane impacted the ground with a relatively shallow flight path angle, in a nose- and right-wing low attitude, with a significant amount of horizontal energy.

All major airplane and engine components were identified in the wreckage, and no indications of any pre-impact mechanical deficiencies or failures were observed. The flaps were in the fully retracted position, which was the climb-cruise configuration, likely indicative that the pilot was not attempting a landing when the impact occurred. The undamaged condition of the artificial horizon gyro rotor and internal case suggested a possibility that the device was not operating, but the actual operating status of the instrument at the time of the accident could not be determined. Even if the artificial horizon was inoperative, external visual references should have been sufficient to enable the pilot, albeit possibly with some difficulty, to maintain the proper airplane attitude and flight path.

Some fibrous lint-like material was found in the carburetor fuel inlet screen; the material was foreign to the airplane fuel system, but it was not determined when or by what means the lint was introduced into the system. The lint did not appear to have any adverse effect on engine operation; propeller damage was consistent with the engine developing significant power at the time of impact. Airplane fueling information and published performance data indicated that the airplane had sufficient fuel onboard for a return flight to the airport of origin.

About 5 weeks before the accident, the pilot had completed a night flight in the accident airplane from his home airport to the accident airport and back, which indicated that he was at least somewhat familiar with the accident airport. The reason for the pilot's use of a right traffic pattern instead of the designated left traffic pattern for his departure could not be determined.

Although the pilot had documented color vision deficiencies, this condition likely did not contribute to the accident sequence. The pilot had relatively limited total and night flying experience, and the night and local terrain were very dark. Given the signatures of engine power and lack of mechanical anomalies found during postaccident examination, it is not likely that the accident was the result of a loss of engine power. Further, correlation of debris field information with the descent angle depicted in the surveillance imagery frames indicated that the descent path was too shallow to be consistent with an aerodynamic stall. Additionally, the airplane's impact attitude and the distribution of the wreckage were inconsistent with a loss of control due to spatial disorientation. It is possible that the pilot lost his situational awareness while maneuvering onto the right downwind leg which resulted in the airplane descending rapidly to ground impact. 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's loss of situational awareness shortly after takeoff over a sparsely lit area in dark night conditions, which resulted in a rapid descent to ground impact. 

Findings

Personnel issues
Situational awareness - Pilot (Cause)
Aircraft control - Pilot (Cause)

Environmental issues
Dark - Effect on personnel (Cause)
Dark - Effect on operation (Cause)

Factual Information

History of Flight

Maneuvering
Loss of control in flight (Defining event)
Abrupt maneuver
Collision with terr/obj (non-CFIT)

On November 19, 2017, about 1756 Pacific standard time, a Cessna 152 airplane, N24987, was destroyed when it impacted terrain shortly after takeoff from Tehachapi Municipal Airport (TSP), Tehachapi, California. The private pilot received fatal injuries. The airplane was operated by Barnes Aviation as a Title 14 Code of Federal Regulations Part 91 personal flight. Night visual meteorological conditions prevailed, and no flight plan was filed for the flight. The flight was originating at the time of the accident; the pilot's intended destination was not determined.

The pilot had rented the airplane from Barnes Aviation, a fixed-base operator (FBO) located at General William J. Fox Airfield (WJF), Lancaster, California. According to a representative of the FBO, the airplane fuel tanks were filled, and then the airplane was flown about 1.4 hours before its pickup by the accident pilot. The airplane was not fueled after that flight, or after the flight to TSP.

According to a flight instructor who was employed by the FBO, the pilot had reserved the airplane for a few hours in the afternoon of the accident. About 1522, the flight instructor was asked by another FBO employee to pull the airplane out of a hangar for the pilot. The airplane had been removed from the hangar by about 1530, followed by the meeting of the pilot and that instructor for the first time. In response to the instructor's query, the pilot told the instructor that he planned to fly "to Rosamond then maybe up north for a little while." Rosamond Skypark Airport (L00), Rosamond, California, was located about 8 nautical miles north of WJF. About 1535, the pilot began his preflight inspection. About 1545, the pilot started the engine of the airplane, and the instructor saw the airplane take off from runway 6 about 1555. The instructor did not mention anything unusual or concerning about the pilot's actions. The pilot's route of flight, or whether he landed at any other airports between the time of his departure from WJF and his arrival at TSP, could not be determined.

TSP was located about 26 miles northwest of WJF. Surveillance imagery from three collocated cameras at TSP captured the airplane taxi into and stop in the transient parking area about 1628. The pilot secured the airplane and walked to a nearby restaurant to eat. He returned to the airplane about 1738, by which time night had fallen. The pilot started the engine about 1749 and taxied from the parking spot about 1 minute later. A set of lights presumed to be the accident airplane could be seen departing from TSP runway 29 about 1755. The surveillance imagery appeared to depict the airplane maneuvering in a manner consistent with a right traffic pattern after takeoff, followed by a rapid descent.

Multiple witnesses saw or heard the descent and/or impact and telephoned 911 to report the accident. A ground search aided by illumination from a law enforcement helicopter searchlight located the wreckage in a ranch pasture just north of TSP. The wreckage was examined on scene. A handheld Garmin GPS II Plus device was recovered on scene and was sent to the NTSB Recorders Laboratory for possible data download. Damage to the device precluded the recovery of any data. The airplane wreckage was then recovered to a secure storage facility for subsequent detailed examination. 



Pilot Information

Certificate: Private
Age: 49, Male
Airplane Rating(s): Single-engine Land
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 With Waivers/Limitations
Last FAA Medical Exam: 04/15/2016
Occupational Pilot: No
Last Flight Review or Equivalent: 08/22/2017
Flight Time:  152 hours (Total, all aircraft), 6 hours (Last 90 days, all aircraft), 3 hours (Last 30 days, all aircraft), 0 hours (Last 24 hours, all aircraft)

Federal Aviation Administration (FAA) records indicated that the pilot held a private pilot certificate with an airplane single-engine land rating. At the time of the accident, the pilot had logged a total flight experience of about 152 hours, including about 12 hours of night experience. His most recent flight review was completed in August 2017. On October 8, 2017, he had flown solo in the accident airplane from WJF to TSP and back at night and conducted 3-night landings.

Aircraft and Owner/Operator Information

Aircraft Make: CESSNA
Registration:N24987 
Model/Series: 152 NO SERIES
Aircraft Category: Airplane
Year of Manufacture: 1977
Amateur Built: No
Airworthiness Certificate: Utility
Serial Number: 15280496
Landing Gear Type: Tricycle
Seats: 2
Date/Type of Last Inspection: 09/29/2017, 100 Hour
Certified Max Gross Wt.: 1669 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 11168 Hours as of last inspection
Engine Manufacturer: LYCOMING
ELT: C91 installed, activated, did not aid in locating accident
Engine Model/Series: O-235 SERIES
Registered Owner: SHOULING & PHILIP ENTERPRISE
Rated Power: 105 hp
Operator: On file
Operating Certificate(s) Held: None

FAA information indicated that the airplane was manufactured in 1977 and registered to the current owner in November 2011. The two-place, high-wing airplane was equipped with a Lycoming O-235 series engine. Maintenance records indicated that the airplane had accumulated a total time in service of about 11,168 hours and that the engine had accumulated a time since major overhaul of about 2,795 hours. The most recent annual inspection was completed in April 2017, and the most recent 100-hour inspection was completed in September 2017.

According to the airplane manufacturer's published performance data, the typical minimum flight endurance, not including a 45-minute reserve, is about 3 hours. Actual endurance can be increased significantly, primarily as a function of power setting, cruise altitude, and engine leaning procedures. Calculations that accounted for the estimated flight time of the airplane since its last known refueling indicated that the airplane likely had at least 1 hour and 45 minutes' worth of fuel on board at the time of the accident.

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Night/Dark
Observation Facility, Elevation: TSP, 4001 ft msl
Distance from Accident Site: 0 Nautical Miles
Observation Time: 1755 PST
Direction from Accident Site: 0°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 3 knots /
Turbulence Type Forecast/Actual: / None
Wind Direction: 320°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 30.13 inches Hg
Temperature/Dew Point: 10°C / 0°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Tehachapi, CA (TSP)
Type of Flight Plan Filed: None
Destination:
Type of Clearance: None
Departure Time: 1755 PST
Type of Airspace: 

The 1755 TSP automated weather observation included winds from 320° at 3 knots, visibility 10 miles, clear skies, temperature 7° C, dew point 0° C, and an altimeter setting of 30.13 inches of mercury.

Local sunset occurred at 1646, and civil twilight ended at 1713. The moon was a waxing crescent with 2% of its disc illuminated. Local moonset occurred at 1802. 

Airport Information

Airport: Tehachapi Municipal (TSP)
Runway Surface Type: N/A
Airport Elevation: 4001 ft
Runway Surface Condition:
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: Unknown

TSP was located just north of the city of Tehachapi; both were situated in an elevated, wide valley surrounded by mountainous terrain. The area surrounding TSP and the city was primarily ranchland with very sparse illumination. TSP was equipped with a single paved runway, designated 11/29. The runway was 4,040 ft long, and airport elevation was 4,001 ft above mean sea level. TSP was not equipped with an air traffic control tower. Runway 29 was designated as having a left-hand traffic pattern.

TSP was equipped with taxiway and runway lights, and a rotating beacon. The airport lighting was operating at the time of the accident. A peak situated about 3/4-mile beyond the departure end of runway 29 rose about 300 ft above the airport elevation and was marked with a red light.



Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 35.142778, -118.441111 

The initial impact point was located about 350 ft west-northwest of, and offset about 2,050 ft north-northwest of, the runway 11 threshold. The accident site terrain was hard-packed, dry earth, flat and level, with mostly dried grass and some low, dried shrubs. All airplane components were accounted for at the accident site. No evidence consistent with in-flight fire or in-flight structural failure was observed.

Ground scars were consistent with the airplane impacting the terrain in a nose- and right-wing-low attitude. The right wingtip strike was the beginning of the ground scar. The earliest identifiable piece of wreckage was an outboard fragment of the right aileron. A ground scar consistent with the right main landing gear (RMLG) was located about 20 ft beyond the right wingtip strike. Scarring consistent with nose landing gear or propeller contact began about 10 ft beyond the RMLG strike. The ground scars and airplane damage were consistent with the wreckage tumbling and sliding before coming to rest.

The main wreckage consisted of the engine, wings, empennage, and most of the fuselage. The main wreckage came to rest about 250 ft, on a bearing of 138° true, from the initial impact point. Several items, including the propeller, some engine accessories, and some fuselage fragments, formed a debris field between the initial impact point and the main wreckage. The debris field orientation was within about 14° of the runway alignment. Several high-density items such as the battery and the alternator core came to rest several hundred feet beyond the main wreckage.

Both wings exhibited full-span, aft-direction crush damage along their leading edges.

Both lift struts remained attached to their respective wings but were separated from the fuselage. Both wings retained their respective fuel tank caps. Both flaps remained fully attached to their respective wings; the flaps were relatively undamaged and were found in positions consistent with being fully retracted at the time of impact. Both ailerons remained attached to their respective wings.

The vertical stabilizer with rudder and horizontal stabilizers with the elevators remained attached to the aft fuselage. The pitch trim tab remained attached to the right horizontal stabilizer.

All wing and empennage control surfaces retained their respective balance weights. Control continuity was established from both ailerons to the fuselage break in the cockpit. Control continuity was established from both elevators, the pitch trim tab, and the rudder to the fuselage break in the cockpit.

The cockpit/cabin was found torn open. The windshield was reduced to numerous small fragments. Both cabin doors were completely fracture-separated from the airplane. The flap handle was found in the "Up/Retract" position. The elevator trim indicator and trim wheel were impact damaged. The trim actuator measurement indicated a 5┬║-tab-trailing-edge-up position. The control lock was found stowed in the back pocket of the right seat.

The primer, throttle, and mixture controls in the cockpit were found in their full forward positions; the throttle and mixture cables were continuous to the carburetor. The carburetor heat control was not identified in the wreckage. The fuel selector was found in the "ON" position. The master switch and all circuit breakers were absent from their receptacles.

The ignition switch was found in the "OFF" position with the key installed and bent to the left.

The engine remained partially attached to the engine mount and forward fuselage. The engine was relatively intact, but sustained impact damage in the aft and up directions. There was significant ductile bending of the exhaust system components. Several engine accessories or external components were fracture-separated from the engine. There was no evidence of abnormal external oil streaking observed on any of the airplane skins. No evidence of any pre-impact catastrophic failures was observed.

The vacuum pump remained securely attached to its mounting pad on the engine accessory face. The pump was removed and disassembled. The shear coupling, rotor, and vanes were all intact. The rotor rotated freely by hand, and all vanes moved freely in their slots. The artificial horizon was fracture-separated from its mount and was missing its face. The gyro rotor case was opened for examination and no internal scoring or other damage was observed.

The engine was separated from the attached wreckage for further examination. The top spark plugs were removed and examined; their appearance was consistent with normal operation. The crankshaft was rotated manually and freely in both directions. Thumb compressions was obtained in proper sequence on all four cylinders. Clean, uncontaminated oil was observed at all four rocker box areas. Mechanical continuity and proper operational sequence were established throughout the rotating group, valve train, and accessory section.

The combustion chamber of each cylinder was examined via borescope; all cylinders and valves exhibited normal operational signatures, and no damage was observed. No oil residue was observed in the exhaust system gas path. The oil displayed evidence of metal contamination.

Examination of the gascolator screen and the forward and aft strainers at each wing tank found no visible contaminants. The engine compartment fuel line was found to be in place and secure at its respective B nuts; however, the fitting at the carburetor inlet was fracture-separated, consistent with overload. The carburetor was undamaged and remained securely attached to the engine. Reliable positions of the mixture and throttle settings at the time of impact could not be determined.

No external fuel staining was observed on the carburetor. The carburetor was opened for examination. All internal locking tabs and safety devices of the carburetor were in place and properly secured. The fuel bowl was free of visible contaminants. The float assembly remained secure at the mounting and free of damage. The metal float pontoons exhibited no evidence of rubbing against the wall of the bowl. The right float exhibited slight hydraulic crushing on each side. The left float appeared normal.

The carburetor fuel inlet screen was found properly installed. The fuel inlet screen contained a loosely packed material consistent with lint that constituted approximately 50% of the screen internal volume. The material was submitted to the NTSB Materials Laboratory for identification. The material consisted of two different fibrous materials: one blue, and one reddish-brown in color. A spectrometer was used to collect and process infrared wavelength absorbance spectra of the material; the spectral results indicated that the material was most likely cellulose, which is found in natural plant fibers such as cotton. The material was foreign to the airplane fuel system, and it was not determined when or by what means the lint was introduced into the fuel system.

The left magneto was found securely clamped to its engine mounting pad. Magneto-to-engine timing could not be ascertained due to the destruction of the flywheel. The magneto produced spark at all four plug leads during hand rotation of the drive. The impulse coupler drive was intact and properly safetied.

The right magneto was fracture-separated from its engine mounting pad and impact-damaged. The fracture surface signatures at the magneto mounting flange were consistent with overload. The pieces of magneto flange that remained at the mounting pad were securely clamped. Magneto-to-engine timing could not be ascertained. The right magneto would not produce spark when hand-rotated at the drive due to impact damage. The impulse coupler drive was intact and properly safetied.

The single-piece, all-aluminum, two-bladed, fixed-pitch propeller was fracture-separated from the engine at the crankshaft flange. The fracture surfaces exhibited signatures consistent with overload due to rotation. The propeller blades displayed leading edge gouging, torsional twisting, chordwise striations across the cambered surfaces, and trailing edge "S" bending. The signatures were consistent with significant rotational energy being applied to the crankshaft at the time of impact.

Medical And Pathological Information

The Kern County, Bakersfield, California, Sheriff-Coroner's Office autopsy report indicated that the cause of death was "blunt injuries," and that there were "no signs of natural disease such as to qualify as clues to a cause of the accident."

FAA medical records indicated that the pilot had failed the color vision test on the four medical certificate applications that were on file. His FAA medical examiner(s) did not identify any significant adverse conditions, and his most recent third-class FAA medical certificate was issued in April 2016.

Toxicology testing of the pilot's tissue samples at the FAA Forensic Sciences Laboratory was negative for carbon monoxide and ethanol. Ranitidine was detected in urine and blood samples. This medication is used to treat intestinal ulcers, gastroesophageal reflux disease, heartburn associated with acid indigestion, and other conditions where the stomach produces too much acid. The FAA has no limitations on its use by pilots.

Additional Information

TSP Surveillance Camera Imagery

Three surveillance cameras that captured the accident airplane were mounted atop a hangar located on the south-southwest side of the runway, adjacent to the transient parking ramp. The camera views included most of the transient ramp, the eastern side of the fuel pit, portions of the runway and its parallel taxiway, and portions of the highway and non-airport property north-northwest of the airport. All three camera channels were recorded as continuous motion imagery. Captured imagery included the arrival of the airplane at the transient parking area, some of the pilot's post- and pre-flight activities, and portions of the taxi-out and accident flight.

After the airplane taxied from the transient parking ramp, the night conditions, airplane distance from the cameras, and camera resolution caused the airplane image to be reduced to a set of whitish lights. The airplane appeared to taxi for the departure runway via the parallel taxiway, and calculations based on time and airplane position indicated that the taxi speed ranged between 11 and 14 knots. The pilot spent about 3 to 4 minutes near the approach end of runway 29 before beginning his takeoff roll. The airplane traversed about 1,300 ft in about 14 seconds during its late takeoff roll, liftoff, and initial climb, yielding an average calculated speed about 54 knots. Another camera captured the airplane in its initial climb; calculations indicated that the climb speed was about 81 knots.

Two of the cameras captured the airplane maneuvering in a manner consistent with it flying the right crosswind and right downwind traffic pattern legs. A few seconds after it appeared to have entered the downwind leg, the airplane descended rapidly toward the ground, and then disappeared from view. The descent took about 7 seconds, and the descent path was depressed about 30° below horizontal in the camera image frames. None of the captured imagery depicted any flashes consistent with a ground impact explosion or any postimpact fire. The image quality precluded any determination of airplane attitude, altitude, distance from the cameras, or specific heading.

Spatial Disorientation & Situational Awareness

According to the FAA publication Pilot's Handbook of Aeronautical Knowledge (PHAK, FAA-H-8083-25):

Spatial disorientation specifically refers to the lack of orientation with regard to the position, attitude, or movement of the airplane in space…. During flight in visual meteorological conditions (VMC), the eyes are the major orientation source and usually prevail over false sensations from other sensory systems. When these visual cues are taken away… false sensations can cause a pilot to quickly become disoriented.

The handbook then stated that "Prevention is usually the best remedy for spatial disorientation. Unless a pilot has many hours of training in instrument flight, flight in reduced visibility or at night when the horizon is not visible should be avoided."

The handbook defined situational awareness as the "accurate perception of the operational and environmental factors that affect the airplane, pilot, and passengers during a specific period of time." The handbook stated that a situationally aware pilot "has an overview of the total operation and is not fixated on one perceived significant factor." The handbook stated that "some of the elements inside the airplane to be considered are the status of airplane systems," and cautioned that "an awareness of the environmental conditions of the flight, such as spatial orientation of the airplane, and its relationship to terrain… and airspace must be maintained."

4 comments:

  1. This is why I think that night VFR is flight in IMC. Once a VFR pilot (me for instance) loses ground reference or is even in unfamiliar surroundings it's not that hard to become disoriented. My personal minimums are now night VFR flights until I finish my instrument rating. Everyone has to make their own choice about this topic, I made mine a long time ago.

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  2. "now night VFR" should be no night VFR...

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  3. Interesting fuel inlet screen contamination- 50% of the screen ........ red and blue fibers ..

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  4. I feel very bad for the pilot and family. I agree with the first comment. Night VFR over the desert is dangerous. Especially with little experience and Tehachapi is very obscure with the hill being on the end of departure. Lesson learned is Aviation is unforgiving for some mistakes

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