Saturday, February 9, 2019

Aerodynamic Stall / Spin: North American SNJ-5 (AT-6D) Texan, N12377, fatal accident occurred April 25, 2018 at Kingsville Naval Air Station (KNQI), Kleberg County, Texas

Steve DeWolf

Steven Kelley DeWolf died doing what he loved, flying his North American SNJ-5 (AT-6D) Texan. Born in France to American bomber pilot Colonel James G. DeWolf and his journalist wife, Frances Ray DeWolf, he was the only star in their universe. The family lived many places around the world, loving the military life and all the travel it involved. They became a very tight-knit group of three. Upon returning to the states, the DeWolfs moved to Dayton, Ohio where Steve's father was stationed. Steve completed high school there in 1971 and following graduation accepted an appointment to the U.S. Naval Academy. He studied at the Academy until his eyesight ended his dream of becoming a Navy pilot. He transferred to the University of Texas after his sophomore year and graduated Phi Beta Kappa in 1975 with highest honors. That fall he entered the University of Texas School of Law, receiving his J.D. with honors in 1978. Steve practiced law in Houston before once again returning to school, this time at Queens' College, University of Cambridge, England. In 1983 he received an LL.M. with honors. Steve did nothing halfway. He practiced law in Southern California until 1988 before returning to his beloved, adopted home state of Texas. In the early 1990s, he received his pilot's license and bought a 1943 Stearman open cockpit biplane. He loved to fly and participated in many airshows. The Stearman had a special place in his heart as it was the type of plane his dad had trained in during WWII. He later bought a more advanced trainer, an SNJ/T-6 Texan, much to his wife's chagrin.  
Charles Pomeroy Skoda

LCDR (ret.) Skoda was an F/A-18 Instructor Pilot and member of the Blue Diamonds squadron out of NAS Lemoore. He served 11 years active duty and 9 years active-reserve. After his active duty service, Charles went on to become a pilot for American Airlines out of Dallas, TX. Following the draw-down of post 9/11, Charles entered the business world and was Director of Leadership for Afterburner, Inc. (2002-2005); Senior Manager of Sales, Marketing and Development for Capitol One Auto Finance (2006-2008); Sr. Vice President of Strategic Operations at Noranda Aluminum Holding Corporation (2009-2014); and Sr. Vice President of Corporate Operations for Brock Group (2015-2016). In 2016, he returned to American Airlines and was an Airbus First Officer based in Miami. 

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


Additional Participating Entity:

Federal Aviation Administration / Flight Standards District Office; San Antonio, Texas

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


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


Aviation Accident Data Summary - National Transportation Safety Board: https://app.ntsb.gov/pdf

http://registry.faa.gov/N12377




Location: Kingsville, TX
Accident Number: CEN18FA147
Date & Time: 04/25/2018, 1225 CDT
Registration: N12377
Aircraft: NORTH AMERICAN SNJ 5
Aircraft Damage: Destroyed
Defining Event: Aerodynamic stall/spin
Injuries: 2 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

Analysis 

The private pilot, who was the owner of the vintage military trainer airplane, and a pilot-rated passenger were conducting a right turn just after takeoff, while still over the runway surface. Witnesses reported that the airplane's bank angle exceeded 90° and the highest altitude achieved was 200-300 ft. above ground level. The airplane then descended nose low and impacted a the ground less than 1 minute after takeoff. Radar data indicated that the airplane's average airspeed during the final portion of the flight was 87 mph and the bank angle reached about 56°, which would have resulted in a load factor of about 1.8g. Airplane performance data indicated that the accelerated stall speed at this load factor was about 95 mph, thus it is likely that, during the turn, the airplane exceeded its critical angle of attack and entered an accelerated stall at an altitude too low for the pilot to recover. Postaccident examination of the airplane did not reveal any anomalies that could be attributed to a preimpact mechanical deficiency.

The airplane was equipped with tandem seating and dual flight controls; the owner was seated in the front seat and the passenger was seated in the rear seat. The removable rear cockpit control stick was found outside of the airplane, and it could not be determined if the stick was installed at the time of the accident. No conclusive determination could be made as to which occupant was manipulating the controls during the accident sequence.

The private pilot was using decongestant and allergy medications. Toxicological testing identified diphenhydramine, a sedating antihistamine, at levels that were likely impairing; however, the extent to which this contributed to the accident could not be determined.

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 airspeed during a steep turn after takeoff, resulting in an exceedance of the airplane's critical angle of attack and a subsequent accelerated stall at an altitude too low for recovery. 

Findings

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

Personnel issues
Aircraft control - Pilot (Cause)

Factual Information

History of Flight

Maneuvering
Aerodynamic stall/spin (Defining event)

Uncontrolled descent

Collision with terr/obj (non-CFIT)

On April 25, 2018, about 1225 central daylight time, a North American SNJ 5 airplane, N12377, was destroyed when it impacted terrain shortly after takeoff from Kingsville Naval Air Station (NQI), Kingsville, Texas. The private pilot and pilot-rated passenger were fatally injured. The airplane was registered to and was being operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91. Day visual meteorological conditions prevailed in the area, and no flight plan was filed for the personal flight, which was originating at the time of the accident with an intended destination of San Marcos Regional Airport (HYI), San Marcos, Texas.

Air traffic control tower personnel reported that the airplane took off on runway 13R and had requested a right teardrop turn for a departure toward the north. Several witnesses reported seeing the airplane in a steep right bank; some witnesses reporting that the bank angle exceeded 90° and the maximum altitude achieved was 200-300 ft above ground level. The airplane descended nose low and the right bank angle decreased before the airplane impacted the ground between runway 17R/35L and taxiway B just south of the intersection of taxiways B and E (Figure 1.).


Figure 1. Airport diagram showing the layout of Kingsville NAS

Review of radar data showed that the airplane began its takeoff roll from runway 13R at 1224:01. The accident flight was captured in 11 radar returns, with the final return at 1224:52. No altitude data was recorded. The airplane's ground track continued along the runway centerline from the takeoff position for about 2,000 ft before making a slight left turn followed by a right turn. The right turn continued to the end of the data and the final recorded position was about 100 ft east of the initial impact point.Based on the final 3 recorded radar returns, the turn radius was estimated to be about 450 ft and the calculated average groundspeed was 87 mph. Based on this information, the calculated bank angle was about 56° during the final portion of the flight. For a level, 56°-banking turn, the calculated flight load factor was 1.8g. Based on the velocity versus load factor (V-N) diagram for the accident airplane, a load factor of 1.8g equated to an accelerated stall speed about 95 mph. The airplane's ground track is depicted in Figure2.

Figure 2. Overhead view of the airplane's ground track

Pilot Information

Certificate: Private
Age: 64, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Front
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: 04/17/2018
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time: 3000 hours (Total, all aircraft)

Pilot-Rated Passenger Information

Certificate: Airline Transport; Commercial
Age: 50, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Rear
Other Aircraft Rating(s): None
Restraint Used: 4-point
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 1 Without Waivers/Limitations
Last FAA Medical Exam: 07/18/2017
Occupational Pilot: Yes
Last Flight Review or Equivalent: 
Flight Time: 5000 hours (Total, all aircraft) 

The pilot, age 64, held a private pilot certificate with an airplane single-engine land rating. His most recent Federal Aviation Administration (FAA) third-class medical certificate was issued on April 17, 2018, with a limitation for corrective lenses. On the application for that medical certificate, the pilot reported 3,000 total hours of flight experience, with 40 hours in the previous 6 months. The pilot's flight logbook was not available for review.

The passenger, age 50, held an airline transport pilot certificate with airplane multiengine land and airplane single-engine land ratings. The single-engine rating was limited to commercial pilot privileges. Military records indicated that he had accumulated at least 2,400 hours of flight experience before his discharge from the military. No civilian flight records were reviewed; however, the pilot reported 5,000 total hours of flight experience on the application for his most recent FAA first-class medical certificate, dated July 20, 2017. The medical certificate listed no limitations.

Aircraft and Owner/Operator Information

Aircraft Make: NORTH AMERICAN
Registration: N12377
Model/Series: SNJ 5
Aircraft Category: Airplane
Year of Manufacture:
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 85086
Landing Gear Type: Retractable - Tailwheel
Seats: 2
Date/Type of Last Inspection: 11/20/2017, Annual
Certified Max Gross Wt.: 5300 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 7718 Hours as of last inspection
Engine Manufacturer: Pratt & Whitney
ELT:
Engine Model/Series: R-1340-AN-1
Registered Owner: On file
Rated Power: 600 hp
Operator: On file
Operating Certificate(s) Held: None

The airplane, serial number 85086, was a single-engine monoplane used to train military pilots during World War II and into the 1970s. It was equipped with retractable conventional (tailwheel) landing gear and tandem seating for two occupants. The airplane was powered by a 600-horsepower Pratt & Whitney R-1340-AN-1 radial reciprocating engine, which drove a 2-blade, constant-speed Hamilton Standard 12D40-6101-12 propeller.

Maintenance records indicated that the most recent annual inspection was completed on November 20, 2017, at an airframe total time of 7,717.7 hours. According to the entry, the engine had accumulated 414.7 hours since its most recent overhaul.

Registration information indicated that the pilot had owned the airplane since 2007. 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: NQI, 50 ft msl
Distance from Accident Site: 0 Nautical Miles
Observation Time: 1232 CDT
Direction from Accident Site: 0°
Lowest Cloud Condition: Few / 3000 ft agl
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 16 knots / 23 knots
Turbulence Type Forecast/Actual: /
Wind Direction: 120°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 30.01 inches Hg
Temperature/Dew Point: 31°C / 13°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Kingsville, TX (NQI)
Type of Flight Plan Filed: None
Destination: Austin, TX (HYI)
Type of Clearance: VFR
Departure Time: 1224 CDT
Type of Airspace: Class D 

At 1232, the weather conditions recorded at NQI included wind from 120° at 16 knots gusting to 23 knots, 10 miles visibility, few clouds at 3,000 ft above ground level (agl), temperature 31°C, dew point 13°C, and an altimeter setting of 30.01 inches of mercury. 

Airport Information

Airport: KINGSVILLE NAS (NQI)
Runway Surface Type: Concrete
Airport Elevation: 50 ft
Runway Surface Condition: Dry
Runway Used: 13R
IFR Approach: None
Runway Length/Width: 8000 ft / 200 ft
VFR Approach/Landing: None



Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 1 Fatal
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: On-Ground
Total Injuries: 2 Fatal
Latitude, Longitude: 27.503889, -97.812222

The initial impact point was in a grass area about 1,200 ft right of the runway 13R centerline and about 3,500 ft from its approach end. Most of the wreckage came to rest on the ramp near taxiway E. The debris path was oriented in a westerly direction with the first impact mark about 20 ft from the east edge of the paved ramp area.

The engine separated from the fuselage and the supercharger section of the engine separated from the cylinder section. The propeller remained attached to the engine with one blade intact, displaying evidence of chordwise scratching on the cambered side and twisting of the outboard portion of the blade toward low pitch. The other blade was missing the outboard 2 ft, which came to rest near the ground scar. There was a propeller slash in the dirt and the broken section of the blade displayed leading edge gouging, chordwise scratching, and bending.

Both wings separated upon impact. The right wing came to rest at the east edge of taxiway B. The fuselage came to rest on its right side about 30 ft west of the right wing. The left wing came to rest about 100 ft further west.

The wing was composed of 3 sections; a center section and 2 outboard wing panels. The right wing and a portion of the center section came to rest upright between the initial impact point and the fuselage. The right portion of the wing center section was crushed and twisted and remained attached to the outboard right wing panel. The outboard portion of the wing panel displayed fire damage and upward bending of the portion outboard of the wing joint. The flap remained attached to the outboard portion of the wing. The inboard portion of the right aileron remained attached to the wing.

The left wing separated at the joint and came to rest upright. The aileron was separated, but the inboard portion was found between the fuselage and left wing. The flap remained attached. The left wing was predominately intact. There was aft, angular crushing damage to the wing tip from the tip to about 3 ft inboard. The leading edge inboard of this damage was intact and showed little deformation.

The fuselage was mostly intact. The steel tube fuselage structure at the firewall was bent aft with more significant bending of the right side of the firewall. The firewall crush angle was indicative of about a 30° right-wing-low impact. The left horizontal stabilizer, elevator, vertical stabilizer, and rudder remained attached. The right horizontal stabilizer and elevator remained attached and were bent upward about 90°.

Flight control continuity was established from the forward cockpit rudder pedals aft to the rudder. The left pushrod connecting the forward and aft cockpit rudder pedals were intact but bent about mid-length. The right rudder interconnect pushrod was broken in two; the forward and aft portions remained attached to their respective rudder pedals. Elevator control continuity was established for the complete cable circuit from the elevator forward to the forward control stick bellcrank, then forward around the firewall-mounted pulley and aft to the elevator. Pulling on the rudder and elevator cables resulted in corresponding movement of the respective surfaces. The aileron control bellcrank remained attached and intact on the torque tube with the aileron control cables still attached to the bellcrank. One cable was about 3 ft long, and the other was about 6 inches long to their respective separation points. Both separations were consistent with overload failure. Aileron control cable continuity within the wings was established through several breaks consistent with overload failure.

The forward cockpit control stick casting was fractured from the torque tube and the stick was fractured from its mount. The removable rear cockpit control stick was found lying on the ramp adjacent to the airplane. Examination could not confirm if the stick had been installed in its socket prior to impact.

The right landing gear remained attached to the wing. The left landing gear was broken loose and came to rest between the fuselage and the left wing.

Examination of the airplane did not reveal any evidence of preimpact mechanical failures or anomalies.

Medical And Pathological Information

Pilot

On his medical certificate application, the pilot reported his use of tamsulosin to treat benign prostate hypertrophy and allopurinol for gout. These medications are generally not considered to be impairing. The pilot reported no other medical conditions or medications.

The Nueces County Medical Examiner, Corpus Christi, Texas, performed an autopsy of the pilot. The cause of death was blunt force trauma. The pilot had moderate to severe coronary artery disease with up to 60% narrowing of the right coronary and 70% narrowing of the left coronary artery. No other significant natural disease was identified.

National Medical Services Laboratory (NMS Labs) testing of cavity blood conducted as part of the autopsy was negative for alcohol and carbon monoxide. Testing detected diphenhydramine at 160 ng/ml; pseudoephedrine at 120 ng/ml, and its metabolite, norpseudoephedrine, at 12 ng/ml; and caffeine.

The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicology testing on specimens of the pilot. Diphenhydramine was detected in urine and at 156 ng/ml in cavity blood; pseudoephedrine was detected in blood and urine; and tamsulosin was detected in cavity blood and urine.

Pseudoephedrine, caffeine, and tamsulosin are generally not considered to be impairing. Diphenhydramine is a sedating antihistamine used to treat allergy symptoms and as a sleep aid. It is available over the counter under the trade names Benadryl and Unisom. The therapeutic range for diphenhydramine is 25.0 to 112.0 ng/ml. Blood concentrations following a single dose of 50 mg diphenhydramine in 10 healthy adults produced an average peak plasma concentration of 66 ng/ml at 2.3 hours. Further, in a driving simulator study, a single 50 mg dose of diphenhydramine impaired driving ability more than a blood alcohol concentration of 0.100%. Diphenhydramine carries the FDA warning, "may impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery)." Compared to other antihistamines, diphenhydramine causes marked sedation; this is the rationale for its use as a sleep aid. Altered mood and impaired cognitive and psychomotor performance may also be observed.

Diphenhydramine undergoes postmortem redistribution where, after death, the drug can leach from storage sites back into blood. Central postmortem blood levels may be about two to three times higher than peripheral levels.

Pilot-Rated Passenger

The pilot-rated passenger reported no medications and had no significant medical conditions during his most recent FAA medical examination.

The Nueces County Medical Examiner's autopsy documented the cause of death as multiple crush injuries. The passenger had moderate coronary artery disease with up to 50% narrowing of the right coronary, 40% narrowing of the left coronary, and 30% narrowing of the circumflex coronary arteries. No other significant natural disease was identified.

NMS Labs forensic toxicology testing of femoral blood conducted as part of the autopsy was negative for alcohol, carbon monoxide, and tested-for drugs.

FAA Bioaeronautical Sciences Research Laboratory toxicology testing detected no carbon monoxide in femoral blood, no ethanol in vitreous, and no tested-for-drugs in urine.

Loss of Control in Flight: Beechcraft E90 King Air, N48TA, fatal accident occurred June 13, 2017 near Sierra Blanca Regional Airport (KSRR), Ruidoso, Lincoln County, New Mexico

Justin Alan and Hayden Alan King


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


Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Albuquerque, New Mexico
Textron Aviation; Wichita, Kansas
Pratt & Whitney; Bridgeport, West Virginia

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



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

Aviation Accident Data Summary - National Transportation Safety Board: https://app.ntsb.gov/pdf


http://registry.faa.gov/N48TA



Location: Ruidoso, NM
Accident Number: CEN17FA227
Date & Time: 06/13/2017, 2210 MDT
Registration: N48TA
Aircraft: BEECH E 90
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight
Injuries: 2 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

Analysis 

The commercial pilot had filed an instrument flight rules flight plan and was departing in dark night visual meteorological conditions on a cross-country personal flight. A witness at the departure airport stated that during takeoff, the airplane sounded and looked normal. The witness said that the airplane lifted off about halfway down runway 24, and there was "plenty" of runway remaining for the airplane to land. The witness lost sight of the airplane and did not see the accident because the airport hangars blocked her view.

The wreckage was located about 2,400 ft southeast of the departure end of runway 24. Examination of the accident site indicated that the airplane impacted in a nose-down attitude with a left bank of about 20°. A left turn during departure was consistent with the airport's published instrument departure procedures for obstacle avoidance, which required an immediate climbing left turn while proceeding to a navigational beacon located about 7 miles east-northeast of the airport.

Examination of the wreckage did not reveal any evidence of preimpact mechanical malfunctions that would have precluded normal operation.

The pilot had reportedly been awake for about 15 hours and was conducting the departure about the time he normally went to sleep and, therefore, may have been fatigued about the time of the event; however, given the available evidence, it was impossible to determine the role of fatigue in this event.

Although the circumstances of the accident are consistent with spatial disorientation, there was insufficient evidence to determine whether it may have played a role in the sequence of events. 

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 clearance from terrain after takeoff during dark night conditions. 

Findings

Aircraft
Altitude - Not attained/maintained (Cause)

Environmental issues
Dark - Effect on operation

Factual Information

History of Flight

Enroute-climb to cruise
Loss of control in flight (Defining event)

Collision with terr/obj (non-CFIT)

On June 13, 2017, about 2210 mountain daylight time, a Beech E 90, N48TA, impacted terrain during initial climb after takeoff from runway 24 at Sierra Blanca Regional Airport (SRR), Ruidoso, New Mexico. The commercial pilot and the passenger sustained fatal injuries. The airplane was destroyed by impact forces and postcrash fire. The airplane was registered to King Industries Corporation and was being operated by the pilot under Title 14 Code of Federal Regulations Part 91 as a personal flight. Dark night visual meteorological conditions prevailed at the time of the accident. An instrument rules flight plan was filed for the flight that was originating at the time of the accident and was destined for Abilene Regional Airport (ABI), Abilene, Texas.

The flight plan was filed at 2155 and listed a proposed departure time of 2320 from SRR. The planned flight to ABI was 1 hour 5 minutes, and the fuel on board was 2 hours 50 minutes.

According to the pilot's wife, on the day of the accident, their oldest son played in a championship baseball game, and after the game, the family drove to the airport, arriving about 2130. She said that her husband did "all the preflight checks" of the airplane and then he and their oldest son boarded the airplane. She further said that her husband did an engine runup by the hangar area; everything "looked good, sounded good"; the airplane then taxied to runway 24.

She reported that the airplane lifted off about halfway down the runway, and "plenty of runway" remained for the airplane to "set back down." She further reported that the airplane was airborne by the time it flew in front of her truck, and "everything sounded okay." She said that she did not see any flames from the airplane or its engines. She could not see if there was any smoke, since it was dark outside. She said the takeoff was "normal," and the airplane did not sink. She lost sight of the airplane as it climbed out because her truck was parked by one of the hangars, which blocked her view, and she did not see the accident.

The wreckage was located by first responders about 2,400 ft southeast from the departure end of runway 24. 

Pilot Information

Certificate: Commercial
Age: 39, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: Unknown
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 2 Without Waivers/Limitations
Last FAA Medical Exam: 04/25/2015
Occupational Pilot: No
Last Flight Review or Equivalent: 02/10/2017
Flight Time: 1073 hours (Total, all aircraft), 25 hours (Total, this make and model) 

The pilot held a commercial pilot certificate with airplane single- and multi-engine land and instrument ratings; he also held a mechanic certificate. At the time of his last airman medical examination on March 25, 2015, he reported a flight experience of 400 total hours with no hours in the last 6 months. His second-class airman medical certificate had no limitations.

On an aviation insurance application dated January 31, 2017, the pilot listed a total flight experience of 1,073 hours including 197.1 hours in multi-engine land airplanes, 10 hours of instrument flight experience, and 25 hours of turbine flight experience. The application did not have an entry block for night flight time, and no night flight time was listed in any other area on the application.

Between February 10, 2017 and February 17, 2017, the pilot completed 25.0 hours of BE-90 initial flight training, which was provided by Aviation Group Florida, LLC.

The pilot's wife stated that her husband got up about 0700 to 0730 on the day of the accident and that she did not know what time he went to work. She said that her husband went to his office to do some work and did not have any meetings. She said her husband would typically go to sleep about 2130 to 2200 and wake up at 0700 to 0730.

Aircraft and Owner/Operator Information

Aircraft Make: BEECH
Registration: N48TA
Model/Series: E 90 NO SERIES
Aircraft Category: Airplane
Year of Manufacture: 1978
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: LW-283
Landing Gear Type: Retractable - Tricycle
Seats:
Date/Type of Last Inspection: 02/09/2017,
Certified Max Gross Wt.: 10099 lbs
Time Since Last Inspection:
Engines: 2 Turbo Prop
Airframe Total Time: 12621.9 Hours as of last inspection
Engine Manufacturer: Pratt & Whitney
ELT: Installed, not activated
Engine Model/Series: PT6A-28
Registered Owner: King Industries Corporation
Rated Power: 680 hp
Operator: Pilot
Operating Certificate(s) Held: None

On February 3, 2017, the airplane was sold to King Industries Corporation by Aviation Group Florida, LLC. An aircraft registration application for the airplane was signed by the pilot, whose title was listed as Vice President, on February 3, 2017. 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Night/Dark
Observation Facility, Elevation: SRR, 6814 ft msl
Distance from Accident Site: 1 Nautical Miles
Observation Time: 2155 MDT
Direction from Accident Site: 35°
Lowest Cloud Condition: Clear
Visibility:  
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 12 knots /
Turbulence Type Forecast/Actual: / None
Wind Direction: 220°
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 30.13 inches Hg
Temperature/Dew Point: 19°C / -12°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Ruidoso, NM (SRR)
Type of Flight Plan Filed: IFR
Destination: Abilene, TX (ABI)
Type of Clearance: IFR
Departure Time: 2210 MDT
Type of Airspace: 

According to the U.S. Naval Observatory, Astronomical Applications Department, on June 13, 2017, moon rise in Ruidoso was at 2323, and the phase of the moon was waning gibbous with 85% of the moon's visible disk illuminated.

Airport Information

Airport: Sierra Blanca Regional Airport (SRR)
Runway Surface Type: Asphalt
Airport Elevation: 6814 ft
Runway Surface Condition:
Runway Used: 24
IFR Approach: None
Runway Length/Width: 8120 ft / 100 ft
VFR Approach/Landing: None 

SRR did not have an air traffic control tower. There were two published instrument departure procedures designed for obstacle avoidance while climbing out of the airport area. For departures from runway 24, both procedures required an immediate climbing left turn while proceeding to a navigational beacon located about 7 miles east-northeast of the airport. 

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 1 Fatal
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Fatal
Latitude, Longitude: 33.453056, -105.543056 (est) 

The accident site was located about 2,400 ft southeast of the departure end of runway 24 at an elevation of about 6,756 ft. The airplane wreckage path was on a southeasterly heading and was about 168 ft in length. The terrain from the northwest to the southeast was upsloping and exhibited soot and fire damage to the ground and surrounding trees. The northwest end of the wreckage path had trees with breaks that exhibited a downward slope estimated to be about 20° toward the left as viewed looking southeast. The left wingtip was located near the broken trees. The outboard section of the right wing was located about midway along the wreckage path and to the right side of the path as viewed looking southeast. The remaining wing sections and control surfaces were located along the wreckage path. The southeast end of the wreckage path contained the airplane fuselage and empennage.

Both propellers were separated from the engines and were resting along the debris path. Both propellers exhibited S-shaped bending, leading edge damage, and chordwise scratching consistent with engine power being produced at impact. Postaccident disassembly examination of both propellers revealed witness marks that indicated about a 30° blade angle, which was consistent with mid-range power. None of the propeller blades exhibited a feathered position.

Postaccident disassembly examination of both engines revealed impact and postcrash fire damage. The compressor and turbine sections of both engines exhibited circumferential contact damage of the compressor and turbine disks. There were no mechanical anomalies found that would have precluded normal operation of the engines.

The cockpit avionics, flight instruments, and control panel switches were destroyed by impact forces and fire. The landing gear was found in the retracted position.

Examination of the flight control cables revealed overload separations. The left outboard wing flap was in the retracted position, and the remaining flaps were separated from the wings. 

Medical And Pathological Information

The University of New Mexico Health Sciences Center, Office of the Medical Examiner, Albuquerque, New Mexico conducted an autopsy of the pilot. The autopsy report stated that the cause of death was blunt trauma.

The Federal Aviation Administration's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed forensic toxicology on specimens from the pilot. According to the toxicology report, carbon monoxide and cyanide testing were not performed; no ethanol was detected, and ibuprofen was detected in muscle.



NTSB Identification: CEN17FA227
14 CFR Part 91: General Aviation
Accident occurred Tuesday, June 13, 2017 in Ruidoso, NM
Aircraft: BEECH E 90, registration: N48TA
Injuries: 2 Fatal.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

On June 13, 2017, about 2210 mountain daylight time, a Beech E-90, N48TA, impacted terrain about 2,400 feet southeast of the departure end of runway 24 (8,120 feet by 100 feet, asphalt) Sierra Blanca Regional Airport (SRR), Ruidoso, New Mexico, during a departure climb. The airplane was destroyed by impact forces and post-crash fire. The commercial pilot and a passenger sustained fatal injuries. The airplane was operated by the pilot under 14 Code of Federal Regulations Part 91 as a personal flight. Night visual meteorological conditions prevailed at the time of the accident. An instrument rules flight plan was filed for the flight that was originating at the time of the accident and was destined to Abilene Regional Airport, Abilene, Texas.

The airplane wreckage path was distributed along an approximate heading of 138 degrees and was about 168 feet in length. Both propellers were separated from the engines and were resting along the debris path. Both propellers exhibited S-shaped bending, leading edge damage, and chordwise scratching consistent with engine power.

Varga 2150A Kachina, operated under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91, N4635V: Fatal accident occurred June 01, 2017 in Bowling Green, Ohio

Gary Conklin
Sharing the love of his parents to take to the sky, Gary was an avid pilot and the family farm had its own hangar, runway, and fleet of aircraft ranging from fabric taildraggers he rebuilt by hand with his father to Cessna aircraft used to travel the county.


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

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Cleveland, Ohio

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

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


Aviation Accident Data Summary - National Transportation Safety Board: https://app.ntsb.gov/pdf
 
http://registry.faa.gov/N4635V




Location: Bowling Green, OH
Accident Number: CEN17FA207
Date & Time: 06/01/2017, 1159 EDT
Registration: N4635V
Aircraft: VARGA AIRCRAFT CORP. 2150A
Aircraft Damage: Substantial
Defining Event: Medical event
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

Analysis 

The private pilot was performing a visual flight rules cross-country flight after purchasing the airplane. After flying for about 1 hr 20 minutes, the airplane suddenly entered a spiraling descent from cruise flight. Witnesses observed the airplane flying erratically at low altitude before it impacted an open field; they stated that the engine was running until impact.

Toxicological testing of specimens taken from the pilot found 55% carbon monoxide saturation of blood. At carbon monoxide levels above 40%, people typically experience incapacitating symptoms such as severe confusion, agitation, seizures, loss of consciousness, and death.

Examination of the airplane's heat exchanger showed that the outside casing had either previously been repaired or had been originally constructed of metals with different properties. About one-half of the casing was discolored and exhibited varying signs of corrosion (the other half did not). Small holes were found where corrosion had occurred in the casing material. The holes from the corrosion provided a means for carbon monoxide to enter the cockpit from the exhaust system.

Federal guidelines for annual aircraft inspections require an inspection of the exhaust systems for cracks, defects, and improper attachment during each 100-hour or annual aircraft inspection. Maintenance logbooks indicated that the airplane's most recent annual inspection was completed less than 1 month before the accident. The available maintenance logbooks did not contain any record of repairs or replacement of the heat exchanger. However, the condition of the heat exchanger is indicative of an insufficient annual inspection that did not detect and correct the corroded heat exchanger.

It is likely that impairment caused by acute carbon monoxide poisoning led to the pilot's loss of airplane control. The corrosion in the heat exchanger allowed carbon monoxide to enter the cabin. 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's loss of control due to impairment from carbon monoxide poisoning. Contributing to the accident was the corrosion of the heat exchanger and the failure of maintenance personnel to adequately inspect and repair or replace the exchanger during the most recent annual inspection.

Findings

Aircraft
Engine exhaust - Fatigue/wear/corrosion (Factor)

Personnel issues
Aircraft control - Pilot (Cause)
Carbon monoxide - Pilot (Cause)
Scheduled/routine maintenance - Maintenance personnel (Factor)


Factual Information

HISTORY OF FLIGHT

On June 1, 2017, at 1157 eastern daylight time, a Varga 2150A airplane, N4635V, was destroyed when it impacted terrain near Bowling Green, Ohio. The private pilot was fatally injured. The airplane was privately owned by the pilot, and he was operating it under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. Visual meteorological conditions prevailed for the personal flight, which originated from Tri-City Airport (3G6), Sebring, Ohio, and was en route to Conklin Airport (OI92), Bowling Green, Ohio.

The pilot had recently purchased the airplane and was relocating it to a private airstrip near his home. GPS data recovered from an onboard device showed that the airplane departed 3G6 about 1034 and flew northwest toward OI92. The airplane maintained consistent groundspeeds and headings until 1156, when it entered a left-turning spiral descent. (See figure.)


Figure: Final GPS Data (oriented Northeast up, times are depicted in UTC)

Witnesses observed the airplane flying erratically at low altitude before it impacted terrain. One witness stated, "the airplane was flying very low to the ground and turned to the east almost turning sideways and upside down. The plane flew south and then turned … the plane was nose down, heading north." Each witness reported that the engine was running before impact. The accident location was about 6 miles southeast of the destination airport.

PERSONNEL INFORMATION

AIRCRAFT INFORMATION

The airplane was manufactured in 1977. The airframe maintenance logs located during the investigation were annotated "Logbook #2, 10/2/92." The first work documented in the engine log was an engine overhaul dated June 11, 1992. The first work documented in the propeller log was an annual inspection dated June 23, 2014. The aircraft log recorded 15 annual inspections between 1992 and 2017. The last annual inspection occurred on May 5, 2017.

METEOROLOGICAL INFORMATION

WRECKAGE AND IMPACT INFORMATION

Wreckage and impact signatures were consistent with the fixed-tricycle gear, tandem-seat airplane impacting terrain left-wing-low in an attitude that exceeded 70° nose-low. The impact point and wreckage debris field were contained within an area about 200 ft in diameter. All airplane and engine components were accounted for at the accident location. The propeller was found separated from the engine. Leading edge gouges and chordwise scratches were present on both propeller blades. The fuel selector was found in the "BOTH" position. The left wing and fuel tank were destroyed by impact forces. The right-wing fuel tank contained an undetermined amount of fuel and the tank displayed evidence of hydraulic deformation. Fuel was present in the fuel selector valve and inside the remnants of the engine-driven fuel pump. The flap selector was found at the second notch (extended) position and the flaps were also found in an extended position. No pre-impact anomalies were noted with the airframe or engine during examination at that time.

The NTSB investigator-in-charge conducted an additional examination of the engine on November 1, 2017. Portions of the engine exhaust system, heat exchanger, and associated scat tubing were removed and examined. No nonimpact-related anomalies were identified with the exhaust system or the scat tubing.

The heat exchanger was impact-damaged. The examination also revealed that the outside casing was comprised of metals with different properties. About one-half of the casing was constructed of a material similar to stainless steel that was discolored but showed no indications of corrosion. The remainder of the casing was discolored and exhibited varying signs of corrosion. Small holes were found where corrosion had occurred in the casing material. There were cracks in the casing in areas affected by impact damage. It could not be determined if the cracks were present before impact or resulted from impact forces.

Review of the maintenance logbooks revealed no entries regarding repairs or replacement of the heat exchanger.



MEDICAL AND PATHALOGICAL INFORMATION

The Lucas County Coroner's Office, Toledo, Ohio, conducted an autopsy of the pilot. The cause of death was blunt force trauma.

The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicology testing and identified 55% carbon monoxide in cavity blood. No other tested-for substances were identified.

Carbon monoxide (CO) is an odorless, tasteless, colorless, nonirritating gas formed by hydrocarbon combustion. CO binds to hemoglobin with much greater affinity than oxygen, forming carboxyhemoglobin; elevated levels result in impaired oxygen transport and utilization. Nonsmokers may normally have up to 3% carboxyhemoglobin in their blood; heavy smokers may have levels of 10 to 15%. Acutely, low levels of CO may cause vague symptoms like headache and nausea but increasing levels (40% and above) lead to confusion, seizures, loss of consciousness, and death.

ADDITIONAL INFORMATION

Title 14 CFR Part 43, Appendix D states, in part:

(d) Each person performing an annual or 100-hour inspection shall inspect (where applicable) components of the engine and nacelle group as follows:…

(8) Exhaust stacks - for cracks, defects, and improper attachment. 

Pilot Information

Certificate: Private
Age: 70, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Front
Other Aircraft Rating(s): None
Restraint Used: Unknown
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: BasicMed
Last FAA Medical Exam: 05/18/2015
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time:  793 hours (Total, all aircraft) 

Aircraft and Owner/Operator Information

Aircraft Make: VARGA AIRCRAFT CORP.
Registration: N4635V
Model/Series: 2150A A
Aircraft Category: Airplane
Year of Manufacture: 1977
Amateur Built: No
Airworthiness Certificate: Normal; Utility
Serial Number: VAC-91-78
Landing Gear Type: Tricycle
Seats: 2
Date/Type of Last Inspection: 05/05/2017, Annual
Certified Max Gross Wt.: 4006 lbs
Time Since Last Inspection: 3 Hours
Engines: 1 Reciprocating
Airframe Total Time: 2410 Hours as of last inspection
Engine Manufacturer: Lycoming
ELT: Installed, not activated
Engine Model/Series: O-320-A2C
Registered Owner: On file
Rated Power:
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:
Distance from Accident Site:
Observation Time:
Direction from Accident Site:
Lowest Cloud Condition: Clear
Visibility: 
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: /
Turbulence Type Forecast/Actual: /
Wind Direction:
Turbulence Severity Forecast/Actual: /
Altimeter Setting:
Temperature/Dew Point: 14°C / 9°C
Precipitation and Obscuration:
Departure Point: Sebring, OH (3G6)
Type of Flight Plan Filed: None
Destination: Bowling Green, OH (OI92)
Type of Clearance: None
Departure Time: 1034 CDT
Type of Airspace:

Airport Information

Airport: CONKLIN (OI92)
Runway Surface Type: N/A
Airport Elevation: 675 ft
Runway Surface Condition:
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: None

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 41.339167, -83.598611



NTSB Identification: CEN17FA207
14 CFR Part 91: General Aviation
Accident occurred Thursday, June 01, 2017 in Bowling Green, OH
Aircraft: VARGA AIRCRAFT CORP. 2150A, registration: N4635V
Injuries: 1 Fatal.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

On June 1, 2017, at 1159 eastern daylight time, a Varga 2150A, N4635V, was destroyed when it impacted terrain near Bowling Green, Ohio. The private pilot was fatally injured. The airplane was privately owned and operated by the pilot under 14 Code of Federal Regulations Part 91 as a personal flight. No flight plan was filed and the flight was not receiving any air traffic control services. Visual meteorological conditions prevailed for the cross country flight that originated from Tri-City Airport (3G6), Sebring, Ohio, and was enroute to Conklin Airport (OI92), Bowling Green, Ohio.

The pilot had recently purchased the airplane and he was relocating the airplane to a private airstrip near his home. Witness observations were consistent with the airplane flying at low altitude and maneuvering erratically before it impacted. One witness stated "the airplane was flying very low to the ground and turned to the east almost turning sideways and upside down. The plane flew south and then turned … the plane was nose down, heading north." Each witness reported the engine was running prior to impact. The accident location was about six miles southeast of the destination airport.

The fixed tricycle gear, tandem seat airplane impacted terrain left wing low and greater than 70 degrees nose low pitch. The impact point and wreckage debris field was contained within an area about 200 feet in diameter. As first viewed, all airplane and engine components were accounted for at the accident location. The propeller had separated from the engine during impact. Leading edge gouges and chord wise scratches were present on both propeller blades. The fuel selector was found in the "both" position. The left-wing and fuel tank was destroyed by impact forces. The right-wing fuel tank had an undetermined amount of fuel visually present and the tank had evidence of hydraulic deformation. Fuel was present during examination at the fuel selector valve and inside the remnants of the engine driven fuel pump. The flap selector was found at the second notch position and the flaps were found in an extended position. No pre-impact anomalies were noted with the airframe or engine during examination.