Wednesday, March 06, 2019

Loss of Engine Power (Total): Cessna 152, N89904, accident occurred April 25, 2018 near Cullman Regional Airport (KCMD), Alabama

The National Transportation Safety Board did not travel to the scene of this accident.

Additional Participating Entity:

Federal Aviation Administration / Flight Standards District Office; Birmingham, Alabama

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/N89904



Location: Cullman, AL
Accident Number: CEN18LA151
Date & Time: 04/25/2018, 1714 CDT
Registration: N89904
Aircraft: CESSNA 152
Aircraft Damage: Substantial
Defining Event: Loss of engine power (total)
Injuries: 1 Minor
Flight Conducted Under: Part 91: General Aviation - Personal 

Analysis

After reaching a cruise altitude about 2,500 ft above ground level, the private pilot pulled the engine mixture control toward the lean position too far, and the engine lost total power. The pilot pushed the engine mixture control to the full rich position and attempted unsuccessfully to restart the engine. After one restart attempt, he chose to execute a forced landing, during which the airplane nosed over and sustained damage to the right wing.

Postaccident examination and an engine test run revealed no evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation. The pilot did not activate carburetor heat during the flight or after the engine lost power. At the time of the power loss, nearby weather was conducive to the formation of serious carburetor ice at descent power; however, because of the airplane’s altitude and the limited amount of time available, the investigation could not determine whether carburetor icing contributed to his inability to restart the engine. It is likely that the pilot leaned the mixture too much, which resulted in the engine losing total power. 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot’s inadvertent engine shutdown due to excessive leaning of the engine and his subsequent inability to restart the engine.

Findings

Personnel issues
Incorrect action performance - Pilot (Cause)

Factual Information 

On April 25, 2018, at 1714 central daylight time, a Cessna 152 airplane, N89904, was substantially damaged during a forced landing after departing from Cullman Regional Airport (CMD), Cullman, Alabama. The pilot sustained minor injuries. The airplane was registered to and operated by Guest Aviation LLC under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. Day visual meteorological conditions prevailed for the flight, which departed about 1709 and was destined for Northeast Alabama Regional Airport (GAD), Gadsden, Alabama.

According to the pilot, he departed CMD and climbed to about 2,500 ft above ground level. As he pulled the mixture control toward a lean position for cruise flight, the engine lost power. He pushed the mixture control to a full rich position and attempted unsuccessfully to restart the engine.

The pilot stated that the propeller continued to rotate after the engine lost power. Without an easily accessible engine restart checklist to reference, he relied on memory during the engine restart attempt. The pilot stated he "went through the emergency check, which included the avionics, master switch, fuel selector valve, mixture, and the primer…. although the engine was attempting to restart, it never regained full power".

The pilot did not activate carburetor heat during the flight and thought the throttle lever probably remained at a cruise power setting after the engine lost power. After one restart attempt, he turned his attention to maintaining a proper glide speed and searched for a forced landing area. After identifying a suitable area, he executed a forced landing into a field, during which the airplane nosed over and damaged the right wing.

Examination of the airplane at the accident site revealed the carburetor heat control was in the off position. The engine was started and ran normally at various power settings. No anomalies were noted with the engine or fuel system.

The recorded temperature and dew point data from a nearby weather station were plotted on a carburetor icing chart. The charted data showed that the weather was conducive to moderate icing at cruise power and serious icing at descent power about the time of the engine power loss.

According to the Pilot's Handbook of Aeronautical Knowledge:

When conditions are conducive to carburetor icing during flight, periodic checks should be made to detect its presence. If detected, full carburetor heat should be applied immediately, and it should be left in the ON position until you are certain that all the ice has been removed. If ice is present, applying partial heat or leaving heat on for an insufficient time might aggravate the situation. In extreme cases of carburetor icing, even after the ice has been removed, full carburetor heat should be used to prevent further ice formation. A carburetor temperature gauge, if installed, is very useful in determining when to use carburetor heat.

History of Flight

Enroute-cruise
Loss of engine power (total) (Defining event)

Emergency descent
Off-field or emergency landing

Landing
Hard landing
Nose over/nose down

Pilot Information

Certificate: Private
Age: 20, 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 3 Without Waivers/Limitations
Last FAA Medical Exam: 09/07/2016
Occupational Pilot: No
Last Flight Review or Equivalent: 03/22/2018
Flight Time:  135 hours (Total, all aircraft), 72 hours (Total, this make and model), 90 hours (Pilot In Command, all aircraft), 36 hours (Last 90 days, all aircraft), 15 hours (Last 30 days, all aircraft), 1 hours (Last 24 hours, all aircraft) 



Aircraft and Owner/Operator Information

Aircraft Make: CESSNA
Registration: N89904
Model/Series: 152 NO SERIES
Aircraft Category: Airplane
Year of Manufacture: 1978
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 15282911
Landing Gear Type: Tricycle
Seats: 2
Date/Type of Last Inspection: 11/03/2017, Annual
Certified Max Gross Wt.: 1669 lbs
Time Since Last Inspection: 52 Hours
Engines: 1 Reciprocating
Airframe Total Time: 10878 Hours at time of accident
Engine Manufacturer: LYCOMING
ELT: Installed, activated, aided in locating accident
Engine Model/Series: O-235 SERIES
Registered Owner: GUEST AVIATION LLC
Rated Power: 135 hp
Operator: GUEST AVIATION LLC
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: K3A1, 963 ft msl
Distance from Accident Site: 13 Nautical Miles
Observation Time: 1715 EDT
Direction from Accident Site: 302°
Lowest Cloud Condition: Clear
Visibility: 10 Miles
Lowest Ceiling:  None
Visibility (RVR):
Wind Speed/Gusts: 6 knots / 15 knots
Turbulence Type Forecast/Actual: None / None
Wind Direction: 330°
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 29.98 inches Hg
Temperature/Dew Point: 22°C / 9°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: CULLMAN, AL (CMD)
Type of Flight Plan Filed: VFR
Destination: GADSDEN, AL (GAD)
Type of Clearance: None
Departure Time: 1709 EDT
Type of Airspace: Class E

Wreckage and Impact Information

Crew Injuries: 1 Minor
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Minor
Latitude, Longitude: 34.152778, -86.634722 (est)

Midair Collision: Cirrus SR20, N486DA and Cirrus SR22, N816CD, accident occurred March 16, 2018 at Palatka Municipal Airport (28J), Putnam County, Florida


The National Transportation Safety Board did not travel to the scene of this accident.

Additional Participating Entity: 

Federal Aviation Administration / Flight Standards District Office; Orlando
Cirrus Aircraft; Duluth, Minnesota 
L3 Commercial Training Solutions; Sanford, Florida

N486DA  Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf


N486DA  Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms



Location: Palatka, FL
Accident Number: ERA18LA109A
Date & Time: 03/16/2018, 1038 EDT
Registration: N486DA
Aircraft: CIRRUS DESIGN CORP SR20
Aircraft Damage: Substantial
Defining Event: Midair collision
Injuries: 2 None
Flight Conducted Under:  Part 91: General Aviation - Instructional 

Analysis

A Cirrus SR22 flown by a private pilot and a Cirrus SR20 flown by a pilot undergoing instruction and a flight instructor were performing touch-and-go landings at the airport. The pilot of the SR22 and the flight instructor of the SR20 reportedly announced their positions on the airport’s common traffic advisory frequency (CTAF) as they flew around the airport traffic pattern. The SR22 pilot and the SR20 flight instructor both reported that they heard another pilot announce they were on a 6-mile final for the runway. The SR22 pilot turned onto the base leg and then onto final. The SR20 flight instructor stated that, because an airplane they had in sight was on short final approach, he chose to have the pilot undergoing instruction extend the downwind leg. When they were abeam the airplane that was on final, they turned onto base leg and then onto final. When the SR20 pilot undergoing instruction was just about to flare, the flight instructor heard “an explosion.” When the SR22 was over the runway about ready to begin to flare, the pilot heard a "bang" and the nose came up; the two airplanes had collided. None of the pilots in either airplane reported seeing the other airplane before the collision. Both airplanes sustained substantial damage. 

The pilot of the SR22 indicated that he could not understand some calls from the SR20, and the flight instructor of the SR20 indicated that he did not hear some radio calls from the SR22. Postaccident examinations of the radios and audio panels installed in the SR22 revealed no evidence of preimpact failures or malfunctions that would have precluded normal operation. At least one of the radios was tuned to the airport CTAF, and the audio select panel was configured to use that radio to transmit and receive audio. Functional testing revealed that both of the SR22’s radios and the audio panel performed with no anomalies noted. Postaccident testing of the radios and audio select panel in the SR20 revealed no evidence of preimpact failures or malfunctions that would have precluded normal operation, although damage sustained during the accident prevented a successful functional test of the comm 1 radio antenna’s functionality. Both of the radios in the SR20 were found set to the airport CTAF, but the microphone/transmit selector on the audio panel was set to comm 3. The investigation could not determine when the microphone/transmit selector was set to the comm 3 position. Had the selector been inadvertently set in this position by the S20 flight crew during their flight, it would have resulted in their traffic pattern position reports not being broadcast over the CTAF. Review of certified audio recordings from the departure airports for both airplanes and another airport for the SR22 revealed that the beginning of one transmission from the SR22 pilot was not clearly enunciated and that several portions of transmissions from both SR20 pilots were difficult to discern and/or were poorly enunciated.  Because there was no audio recording of transmissions at the accident airport, it could not be determined whether the clarity or lack of transmissions from either flight crew contributed to the accident. 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
Both pilots’ and the flight instructor’s failure to identify, see, and avoid the other airplane, which resulted in a midair collision. 

Findings

Personnel issues
Monitoring other aircraft - Pilot (Cause)
Monitoring other aircraft - Pilot of other aircraft (Cause)
Monitoring other aircraft - Instructor/check pilot (Cause)
Communication (personnel) - Pilot
Communication (personnel) - Pilot of other aircraft
Communication (personnel) - Instructor/check pilot

Factual Information

History of Flight

Landing-flare/touchdown
Midair collision (Defining event)

Hard landing

On March 16, 2018, about 1038 eastern daylight time, a Cirrus Design Corp (Cirrus) SR22, N816CD, collided with a Cirrus SR20, N486DA (using call sign Connection 461), while both airplanes were on approach to land at Palatka Municipal – Lt. Kay Larkin Field (28J), Palatka, Florida. There were no injuries to the pilot of the SR22, or to the flight instructor and pilot undergoing instruction in the SR20. Both airplanes were substantially damaged. Both airplanes were being operated under the provisions of Title 14 Code of Federal Regulations Part 91; the SR20 was conducting an instructional flight. Visual meteorological conditions prevailed at the time and no flight plan was filed for either flight. The SR22 flight originated about 0932 from Jacksonville Executive Airport at Craig (CRG), Jacksonville, Florida, while the SR20 flight originated about 0953 from the Orlando Sanford International Airport (SFB), Orlando, Florida.

The pilot of the SR22 stated that after takeoff he proceeded to 28J, and with his radio tuned to the common traffic advisory frequency (CTAF), he heard transmissions from 2 pilots. The transmissions from one pilot were clear, while the transmissions from the other was not. He continued monitoring the CTAF and flew towards 28J, asking how many aircraft were in the traffic pattern at 28J. The pilot whose transmissions were clear announced two, to which he announced he could not understand the transmissions from the other pilot. At that time he believed the flight instructor of the SR20 asked how do you hear me or words to that effect. He reported the transmission from that pilot was low and he had trouble discerning what was said. While he was trying to determine what was said an unknown pilot said, "I hear you." For safety concerns he flew about 26 nm to Northeast Florida Regional Airport (SGJ), where he performed two touch-and-go (T&G) landings, then, thinking it might be safe at 28J, proceeded there.

The pilot of the SR22 further reported making his initial radio call on the 28J CTAF when the flight was 11 to 12 miles away. The flight continued towards 28J and when he was 6 miles away, he made a position report on the 28J CTAF. At that time there were still the same two airplanes in the traffic pattern. The transmissions from one airplane were "crystal clear", and that pilot reported departing the airport traffic pattern. He flew over 28J at 2,000 ft msl, which he announced, and then turned onto downwind leg for runway 27, flying at 1,000 ft and 100 knots. He called downwind, midfield downwind, base, and final, but did not see the other airplane that was in the airport traffic pattern. He performed a touch-and-go landing on runway 27, then decided to do one more before returning to CRG.

The SR22 pilot made radio calls on the CTAF announcing crosswind, and midfield left downwind, maintaining about 1/4 mile abeam the runway on the downwind leg. When he was abeam the numbers on the downwind leg of the airport traffic pattern flying at 100 knots, he watched an airplane roll onto the runway, and once that airplane began the takeoff roll, he started slowing and added the first notch of flaps. He also heard another airplane announce they were on a 6-mile final for the runway. When the SR22 was 45° from the approach end of the runway, he turned onto base leg of the airport traffic pattern at about 900 ft maintaining 90 knots where he lowered another notch of flaps. He then turned onto final of the airport traffic pattern between 500 and 600 ft making radio calls for each of the legs, but he did not see the other airplane in the airport traffic pattern. He set up for landing maintaining 80 knots on final with full flaps extended, the landing and strobe lights on. When over the runway just about ready to begin to flare, he heard a "bang" sound and the nose came up. At that time he attributed the sound to be associated with a catastrophic engine failure. He did not have control over his airplane which veered to the right.

The flight instructor of the SR20 reported that when near 28J he heard runway 27 was in use. They continued to 28J and descended to 2,500 ft msl. When the flight was 10 miles from 28J, he made his first radio call announcing their position, and intention. The flight continued and he made another radio call when the flight was 7.5 miles from 28J. At the second radio call the pilot of one aircraft announced that he could not hear him well. He switched the radio to comm 2 and made another radio call. A pilot who was on the ground reported that he could hear them loud and clear. He then switched to comm 1 and the radios were working OK. Their flight continued towards 28J, and he announced on the 28J CTAF that they were coming from the south, and would be entering left downwind at a 45° for runway 27. They joined the left downwind for runway 27, and turned base and final making radio calls on the 28J CTAF for each leg of the airport traffic pattern. He announced they would be performing touch-and-go landings and would be remaining in the airport traffic pattern. The PUI completed two landings, and remained in the traffic pattern while the flight instructor announced on the 28J CTAF every call of the airport traffic pattern. While on the downwind leg for the third landing, they heard a pilot announce that they were on a 6-mile final for runway 27. That pilot announced that he was advise when he was near the lake. Because of an airplane that was on short final approach which they had in sight, he elected to have the PUI extend the downwind leg. When they were abeam the airplane that was on final, they turned onto the base leg, which he announced on the CTAF. The PUI then turned onto final, which he announced, and he also announced when the flight was on short final. At that time, he also announced that this would be their last landing, and they would be departing to the northeast. When the PUI was just about to flare, he heard an explosion. Their airplane drifted to the right and stopped.

The flight instructor of the SR20 further reported after coming to rest, he saw a propeller, secured the engine, and turned everything off, but he did not touch the radios, adding that he does not recall how the radios were configured. He believed he would have secured the electrical system before getting out of the airplane, and once out of it never returned to it. He estimated their flight was at 28J for about 20 minutes when the collision occurred.



Flight Instructor Information

Certificate: Flight Instructor; Commercial
Age: 29, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s): None
Restraint Used: 4-point
Instrument Rating(s): Airplane
Second Pilot Present: Yes 
Instructor Rating(s): Airplane Single-engine; Instrument Airplane
Toxicology Performed: No
Medical Certification: Class 1 Without Waivers/Limitations
Last FAA Medical Exam: 07/30/2015
Occupational Pilot: Yes
Last Flight Review or Equivalent: 10/19/2017
Flight Time: 500 hours (Total, all aircraft), 139 hours (Total, this make and model), 440 hours (Pilot In Command, all aircraft), 180 hours (Last 90 days, all aircraft), 65 hours (Last 30 days, all aircraft), 6 hours (Last 24 hours, all aircraft)



Student Pilot Information

Certificate: Private
Age: 27, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 4-point
Instrument Rating(s): None
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 2 Without Waivers/Limitations
Last FAA Medical Exam: 08/10/2017
Occupational Pilot: No
Last Flight Review or Equivalent: 02/21/2018
Flight Time:  71 hours (Total, all aircraft), 5 hours (Total, this make and model), 16 hours (Pilot In Command, all aircraft), 34 hours (Last 90 days, all aircraft), 6 hours (Last 30 days, all aircraft), 2 hours (Last 24 hours, all aircraft)



Aircraft and Owner/Operator Information

Aircraft Make: CIRRUS DESIGN CORP
Registration: N486DA
Model/Series: SR20 NO SERIES
Aircraft Category: Airplane
Year of Manufacture: 2007
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 1831
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection: 03/04/2018, Annual
Certified Max Gross Wt.: 3000 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 8171 Hours at time of accident
Engine Manufacturer: CONT MOTOR
ELT: Installed, activated, did not aid in locating accident
Engine Model/Series: IO-360-ES
Registered Owner: AEROSIM ACADEMY INC
Rated Power: 200 hp
Operator: AEROSIM ACADEMY INC
Operating Certificate(s) Held: Pilot School (141) 

The four seat, low-wing Cirrus SR22 airplane, serial number 0150, was manufactured in 2002. It was equipped with a Garmin GMA 340 audio select panel and two Garmin GNS 430 transceivers. It was not equipped with traffic collision avoidance system (TCAS) or ADS-B. The pilot was not recording audio transmissions, but reported he was wearing a Bose headset and was communicating on the common traffic advisory frequency (CTAF) using the comm 1 radio.

The pilot of the SR22 reported that since becoming a co-owner of the airplane in September 2017, there had not been any work done to the airplane's radios.

The four-seat, low-wing Cirrus SR20 airplane, serial number 20-1831, was manufactured in 2007. It was equipped with a Garmin GMA 340 audio select panel and two Garmin GNS 430W transceivers. It was not equipped with traffic collision avoidance system (TCAS) or ADS-B. None of the occupants were recording audio transmissions. At the time of the collision, the strobes, navigation and landing lights were on.

According to the operator of the SR20, a review of the discrepancy sheets for the period December 1, 2017, through the last discrepancy dated March 14, 2018, revealed no radio-related discrepancies during in that period of time. 



Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: SGJ, 10 ft msl
Distance from Accident Site: 25 Nautical Miles
Observation Time: 1056 EDT
Direction from Accident Site: 45°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 12 knots /
Turbulence Type Forecast/Actual: None / None
Wind Direction: 310°
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 30.16 inches Hg
Temperature/Dew Point: 17°C / 9°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Sanford, FL (SFB)
Type of Flight Plan Filed: None
Destination: Palatka, FL (28J)
Type of Clearance: None
Departure Time: 0953 EDT
Type of Airspace:



Airport Information

Airport: PALATKA MUNI - LT KAY LARKIN F (28J)
Runway Surface Type: Asphalt
Airport Elevation: 47 ft
Runway Surface Condition: Unknown
Runway Used: 27
IFR Approach: None
Runway Length/Width: 6000 ft / 100 ft
VFR Approach/Landing: Touch and Go; Traffic Pattern 

28J was a public use, non-towered airport owned by the city of Palatka, Florida. It was equipped with runways 09/27 and 17/35. The published common traffic advisory frequency (CTAF) was 122.8 MHz, which was not recorded.



Wreckage and Impact Information

Crew Injuries: 2 None
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 None
Latitude, Longitude: 29.658333, -81.683611 (est) 

Postaccident examination of the SR20 revealed the comm 1 antenna, which was mounted on the centerline of the roof, just behind the doors, was missing. That area sustained significant impact-related damage consistent with contact by the propeller from the SR22. The comm 1 and 2 antennas from the SR22 were not damaged.

Both airplanes were powered and the selected radio frequencies and audio select panel were documented. The SR20 comm 1 transceiver was tuned to 122.80 MHz and the comm 2 transceiver was tuned to 122.80 MHz. The comm 1 and 3 radio selector switches were selected to listen on the audio select panel, and comm 3 "MIC" was selected to transmit on the audio select panel. The SR22 comm 1 transceiver was tuned to 122.80MHz and the comm 2 transceiver was tuned to 119.62 MHz. The comm 1 was selected to listen on the audio select panel, and comm 1 "MIC" was selected to transmit on the audio select panel.

Ground testing of the radios installed in the SR20 revealed comm 1 radio was unreadable and comm 2 radio was readable. The positions of the radios were swapped and the previously readable comm 2 radio became unreadable while the comm 1 radio was readable. Detailed examination of both transceivers revealed that they were within the manufacturer's specifications. Functional checks of all comm and MIC audio inputs of the audio select panel revealed that they were also within the manufacturer's specifications.

Ground testing of the radios of the SR22 found both operational in transmit and receive mode. 



Additional Information

Review of Audio Recorded from Other Airports

Review of FAA certified audio recordings from the departure airports for both aircraft, and also SGJ for the SR22 revealed that with respect to the transmissions from the pilot of the SR22, the beginning of one transmission was not clearly enunciated, while several portions of transmissions from both pilots of the SR20 were difficult to discern and/or were poorly enunciated. There was no mention by any air traffic control facility for either flight about any issue with either airplane's radios.



Exemplar Audio Panel Configuration

Testing of an exemplar airplane operated by L3 Commercial Training Solutions revealed that with the audio select panel configured exactly like it had for the SR20 (MIC 3 selected to transmit), with any comm 1 or comm 2 selected to receive, neither radio would transmit when the push-to-talk switch was pressed. Testing also revealed that when electrical power was removed from the airplane, pushing of the buttons on the audio select panel would not change the setting when the audio select panel was powered up again.



Pilots' Postaccident Interactions

The pilot of the SR22 stated that postaccident, he and both pilots of the SR20 interacted, and during that interaction he relayed to the flight instructor that he never saw him and could not understand his calls. The flight instructor indicated, "I made this call, I made the call" referring to position reports on the CTAF. He asked the flight instructor if he heard him and his position report calls to which the flight instructor of the SR20 said yes. The flight instructor was asked why didn't he say something on the CTAF due to the traffic conflict, and his reply was, "I was just wondering why you were on top of us."

The flight instructor of the SR20 reported that after exiting the airplane, he and the pilot of the SR22 talked. During that conversation he was able to confirm that the SR22 pilot was the person who broadcast on the 28J CTAF that he could not hear the SR20's transmissions. He also indicated that after the SR22 pilot had said he could not hear them well, he never heard any more radio calls from him. The pilot of the SR22 indicated to the flight instructor of the SR20 that he never saw their airplane and asked him if he could hear his radio calls. He informed the SR22 pilot that he never heard his radio calls.

Arrival and Departure Time Estimates


Based on departure times, cruise speeds, and distances between departure airports, it is estimated that the SR22 arrived at 28J about 0947, departed about 0954, arrived at SGJ about 1009, departed there about 1017, and arrived at 28J about 1032. The SR20 arrived at 28J about 1017.





N816CD Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf

N816CD  Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms

http://registry.faa.gov/N816CD

Location: Palatka, FL
Accident Number: ERA18LA109B
Date & Time: 03/16/2018, 1038 EDT
Registration: N816CD
Aircraft: CIRRUS DESIGN CORP SR22
Injuries: 1 None
Flight Conducted Under:  Part 91: General Aviation - Personal 

Analysis 

A Cirrus SR22 flown by a private pilot and a Cirrus SR20 flown by a pilot undergoing instruction and a flight instructor were performing touch-and-go landings at the airport. The pilot of the SR22 and the flight instructor of the SR20 reportedly announced their positions on the airport’s common traffic advisory frequency (CTAF) as they flew around the airport traffic pattern. The SR22 pilot and the SR20 flight instructor both reported that they heard another pilot announce they were on a 6-mile final for the runway. The SR22 pilot turned onto the base leg and then onto final. The SR20 flight instructor stated that, because an airplane they had in sight was on short final approach, he chose to have the pilot undergoing instruction extend the downwind leg. When they were abeam the airplane that was on final, they turned onto base leg and then onto final. When the SR20 pilot undergoing instruction was just about to flare, the flight instructor heard “an explosion.” When the SR22 was over the runway about ready to begin to flare, the pilot heard a "bang" and the nose came up; the two airplanes had collided. None of the pilots in either airplane reported seeing the other airplane before the collision. Both airplanes sustained substantial damage. 

The pilot of the SR22 indicated that he could not understand some calls from the SR20, and the flight instructor of the SR20 indicated that he did not hear some radio calls from the SR22. Postaccident examinations of the radios and audio panels installed in the SR22 revealed no evidence of preimpact failures or malfunctions that would have precluded normal operation. At least one of the radios was tuned to the airport CTAF, and the audio select panel was configured to use that radio to transmit and receive audio. Functional testing revealed that both of the SR22’s radios and the audio panel performed with no anomalies noted. Postaccident testing of the radios and audio select panel in the SR20 revealed no evidence of preimpact failures or malfunctions that would have precluded normal operation, although damage sustained during the accident prevented a successful functional test of the comm 1 radio antenna’s functionality. Both of the radios in the SR20 were found set to the airport CTAF, but the microphone/transmit selector on the audio panel was set to comm 3. The investigation could not determine when the microphone/transmit selector was set to the comm 3 position. Had the selector been inadvertently set in this position by the S20 flight crew during their flight, it would have resulted in their traffic pattern position reports not being broadcast over the CTAF. Review of certified audio recordings from the departure airports for both airplanes and another airport for the SR22 revealed that the beginning of one transmission from the SR22 pilot was not clearly enunciated and that several portions of transmissions from both SR20 pilots were difficult to discern and/or were poorly enunciated.  Because there was no audio recording of transmissions at the accident airport, it could not be determined whether the clarity or lack of transmissions from either flight crew contributed to the accident. 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
Both pilots’ and the flight instructor’s failure to identify, see, and avoid the other airplane, which resulted in a midair collision.

Findings

Personnel issues
Monitoring other aircraft - Pilot (Cause)
Monitoring other aircraft - Pilot of other aircraft (Cause)
Monitoring other aircraft - Instructor/check pilot (Cause)
Communication (personnel) - Pilot
Communication (personnel) - Pilot of other aircraft
Communication (personnel) - Instructor/check pilot

Factual Information

History of Flight

Landing-flare/touchdown
Midair collision (Defining event)
Hard landing

On March 16, 2018, about 1038 eastern daylight time, a Cirrus Design Corp SR22, N816CD, collided with a Cirrus Design Corp SR20, N486DA, while both airplanes were on approach to land at Palatka Municipal – Lt. Kay Larkin Field (28J), Palatka, Florida. There were no injuries to the pilot of the SR22, or to the flight instructor and pilot undergoing instruction in the SR20. Both airplanes were substantially damaged. Both airplanes were being operated under the provisions of Title 14 Code of Federal Regulations Part 91; the SR20 was conducting an instructional flight. Visual meteorological conditions prevailed at the time and no flight plan was filed for either flight. The SR22 flight originated from Craig Municipal Airport (CRG), Jacksonville, Florida, while the SR20 flight originated about 0930 from the Orlando Sanford International Airport (SFB), Orlando, Florida.

The pilot of the SR22 stated that after takeoff he proceeded to 28J, but because of difficulty in hearing one pilot, he elected to fly to Northeast Florida Regional Airport, St. Augustine, where he performed several landings. He then proceeded to 28J where he overflew the airport at 2,000 ft. He entered the airport traffic pattern and performed two landings, then remained in the airport traffic pattern for another. He announced his position for crosswind, midfield downwind, base, and final for runway 27. He noticed one pilot could not be heard well on the radio, one airplane was rolling out on the runway, and another airplane was on a 6-mile final. During the landing flare, he saw his propeller strike something, but could not see the airplane that was directly beneath him.

The operator of the SR20 reported that neither the pilot nor the flight instructor were wearing vision restricting devices. The flight instructor stated that the flight proceeded to 28J were they announced their intention to enter the left downwind for runway 27. In response to their call, a pilot advised that he could not hear them well, so he switched the transceiver to Comm 2 and called again. A pilot who was holding short of runway 27 advised he could hear them loud and clear. They remained in the airport traffic pattern announcing every leg of the airport traffic pattern and executed two touch-and-go landings to runway 27. They remained in the airport traffic pattern for their last touch-and-go landing, again announcing every leg of the airport traffic pattern. Due to traffic on final approach to runway 27 they extended the downwind leg of the airport traffic pattern, then turned onto the base and final legs of the airport traffic pattern. While on final approach about to land, they felt a big explosion then came to rest in grass adjacent to the runway.

Aircraft and Owner/Operator Information

Aircraft Manufacturer: CIRRUS DESIGN CORP
Registration: N816CD
Model/Series: SR22 UNDESIGNATED
Aircraft Category: Airplane
Amateur Built: No
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: SGJ, 10 ft msl
Observation Time: 1056 EDT
Distance from Accident Site: 25 Nautical Miles
Temperature/Dew Point: 17°C / 9°C
Lowest Cloud Condition: Clear
Wind Speed/Gusts, Direction: 12 knots, 310°
Lowest Ceiling: None
Visibility:  10 Miles
Altimeter Setting: 30.16 inches Hg
Type of Flight Plan Filed: None
Departure Point: Jacksonville, FL (CRG)
Destination: Palatka, FL (28J)

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:  29.658333, -81.683611 (est)

Loss of Engine Power (Partial): Piper PA-28-140 Cherokee, N3568K, fatal accident occurred February 21, 2018 near Tri-County Airport (1J0), Bonifay, Holmes County, Florida

Clarence E. Bowers Sr. (Eddie Bowers) 
1944 - 2018

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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Birmingham, Alabama
Textron Lycoming; Arlington, Texas
The New Piper Aircraft Company; Vero Beach, Florida

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


Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms 
 
http://registry.faa.gov/N3568K




Location: Bonifay, FL
Accident Number: ERA18FA084
Date & Time: 02/21/2018, 1615 CST
Registration: N3568K
Aircraft: PIPER PA28
Aircraft Damage: Destroyed
Defining Event: Loss of engine power (partial)
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

Analysis 

The owner of the airplane experienced a partial loss of engine power during takeoff following a touch-and-go landing, but was able to complete a 180° turn and land safely back on the runway. During a post-landing engine run-up, the owner was unable to duplicate the problem, so he taxied to his hangar and reported the problem to his mechanic. The mechanic, a commercial pilot, subsequently boarded the airplane, performed an engine run-up, which seemed normal, and elected to fly the airplane around the airport traffic pattern. A witness, who heard and saw the airplane on final approach, stated that the engine was making "small explosions" or "backfire"-like sounds. The airplane subsequently collided with a tree before it impacted the ground and a fence short of the 4000-foot-long runway and was consumed by a postcrash fire.

Examination of the airplane revealed that the No. 4 cylinder exhaust valve was stuck in the "open" position due to excessive deposits from the combustion process. It is likely that the stuck exhaust valve resulted in the partial loss of engine power. Maintenance records revealed that the engine had not been inspected in accordance with a manufacturer service bulletin regarding stuck valves. Had the service bulletin been complied with, it is possible that the accident may have been prevented. Despite the partial loss of engine power that occurred during the previous flight, the pilot flew a traffic pattern that resulted in the airplane descending into trees about 1/4 mile before the runway threshold after the airplane experienced a partial loss of engine power during the accident flight.

The pilot was diabetic, and although his blood glucose was likely not very elevated at the time he died, it was somewhat elevated on average over the preceding few weeks. Elevated blood glucose can cause blurred vision and subjective sensation of fatigue, as well as increased thirst and urination. Unless life-threatening, it does not directly impair decision-making or judgment; thus it is unlikely that the pilot's diabetes contributed to the circumstances of this accident.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
A partial loss of engine power due to a stuck exhaust valve. Contributing to the accident was the pilot's decision to operate an airplane with a known mechanical deficiency and his failure to fly an appropriate traffic pattern that would have allowed the airplane to reach the runway. 

Findings

Aircraft
Recip eng cyl section - Failure (Cause)

Personnel issues
Decision making/judgment - Pilot (Factor)
Incorrect action performance - Pilot (Factor)

Factual Information

History of Flight

Prior to flight
Aircraft maintenance event

Approach
Loss of engine power (partial) (Defining event)

Approach-VFR pattern final

Collision with terr/obj (non-CFIT)

On February 21, 2018, at 1615 central standard time, a Piper PA-28-140, N3568K, was destroyed when it impacted terrain while landing at Tri-County Airport (1J0), Bonifay, Florida. The commercial pilot was fatally injured. The airplane was privately owned and the pilot was operating the airplane under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. Day visual meteorological conditions prevailed and no flight plan was filed for the local flight, which originated from 1J0 about 1600.

The owner stated that he had flown the airplane before the accident flight. He departed runway 19, climbed to 1,800 ft mean sea level, and maneuvered within 3 to 4 nautical miles of the airport for a few minutes. He then reentered the traffic pattern and completed a touch-and-go landing. He stated that the engine operated normally during this portion of the flight; however, during the initial climb after the touch-and-go landing, the airplane "seemed like it didn't want to fly." The owner verified that the throttle, mixture, and carburetor heat were "full forward." He stated that the engine was not popping or shaking and was not running rough, but the engine would not produce full power. The owner declared an emergency, made a 180° turn back to the airport, and landed uneventfully. He then performed an engine run-up and observed no abnormalities. He subsequently taxied the airplane to his hangar and reported the anomaly to his mechanic.

The owner said that the mechanic immediately boarded the airplane, started the engine, and performed a run-up, during which the engine sounded normal. The mechanic informed the owner that he was going to take the airplane for a test flight and asked the owner to join him multiple times. The owner declined and watched as the airplane departed runway 19. The airplane made a left turn and entered the downwind leg of the traffic pattern at a normal traffic pattern altitude. The owner then observed the airplane descend on the downwind leg and turn onto a left base leg before it disappeared behind trees. A few moments later, he saw a plume of smoke and rushed to the accident site, where he observed the airplane engulfed in flames.

A witness stated that he was outside of his home located on the approach to runway 19. He said that the airplane "didn't sound right" as it flew over his home and that the engine sounded as if it were making "little explosions" or "backfires." The witness observed the airplane's main landing gear brush a tall tree on his property then continue south out of view. Shortly thereafter, he heard an impact and saw a fireball.

Pilot Information

Certificate: Commercial
Age: 73, 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 With Waivers/Limitations
Last FAA Medical Exam: 06/26/2016
Occupational Pilot: No
Last Flight Review or Equivalent: 02/14/2017
Flight Time:  816 hours (Total, all aircraft), 30.3 hours (Total, this make and model) 

In addition to holding a mechanic certificate with airframe and powerplant ratings, the mechanic held a commercial pilot certificate with ratings for airplane single- and multi-engine land and instrument airplane. A review of his logbook revealed that he had accrued a total of 816.2 hours of flight experience (30.3 hours were in the accident airplane) as of February 14, 2017, when he completed his last flight review. There were no flights logged after this date. His most recent Federal Aviation Administration (FAA) second-class medical certificate was issued on June 26, 2016.

Aircraft and Owner/Operator Information

Aircraft Make: PIPER
Registration: N3568K
Model/Series: PA28 140
Aircraft Category: Airplane
Year of Manufacture: 1967
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 28-23631
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection: 06/05/2017, Annual
Certified Max Gross Wt.:
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 5207.57 Hours as of last inspection
Engine Manufacturer: LYCOMING
ELT: Installed, not activated
Engine Model/Series: O-320-E2A
Registered Owner: On file
Rated Power: 140 hp
Operator: On file
Operating Certificate(s) Held: None

The low-wing, four seat airplane was equipped with a Lycoming O-320-E2A engine and a two-bladed Sensenich propeller. A review of maintenance records revealed that the last annual inspection was conducted on June 5, 2017, by the pilot, at a tachometer time of 3,951.77 hours, with 715.3 hours since engine overhaul. The airframe total time was 5,207.57 hours. The owner reported that the airplane had only flown a few hours since the annual inspection and that he had not had any problems with the engine before the day of the accident.

The owner purchased 20 gallons of 100LL aviation gasoline before his flight and stated that the total fuel onboard before departure was 50 gallons (48 usable).

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: OZR, 302 ft msl
Distance from Accident Site: 27 Nautical Miles
Observation Time: 1556 CST
Direction from Accident Site: 360°
Lowest Cloud Condition: Clear / 5000 ft agl
Visibility:  10 Miles
Lowest Ceiling: Broken / 6000 ft agl
Visibility (RVR):
Wind Speed/Gusts: 8 knots /
Turbulence Type Forecast/Actual: None / None
Wind Direction: 140°
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 30.28 inches Hg
Temperature/Dew Point: 28°C / 17°C
Precipitation and Obscuration:
Departure Point: Bonifay, FL (1J0)
Type of Flight Plan Filed: None
Destination: Bonifay, FL (1J0)
Type of Clearance: None
Departure Time: 1600 CST
Type of Airspace: Unknown 

1J0 was not equipped with weather reporting equipment. A witness reported that the wind was 10-20 knots from the south, visibility 10 statute miles, and the sky condition was scattered to overcast at the airport at the time of the accident.

At 1556, reported weather at Cairns Army Airfield (OZR), Fort Rucker/Ozark, Alabama, about 27 nautical miles north of 1J0, included wind from 140° at 8 knots, visibility 10 miles, scattered clouds at 5,000 ft, broken clouds at 6,000 ft, temperature 28°C, dew point of 17°C, and an altimeter setting of 30.28 inches of mercury.

Airport Information

Airport: TRI-COUNTY (1J0)
Runway Surface Type: Asphalt
Airport Elevation: 84 ft
Runway Surface Condition: Dry
Runway Used: 19
IFR Approach: None
Runway Length/Width: 4000 ft / 75 ft
VFR Approach/Landing: Forced Landing; Full Stop; Traffic Pattern 

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 30.000000, -85.000000 (est) 

Examination of the area surrounding the accident site revealed damage that was consistent with the airplane striking a 60-ft-tall tree located about 1/4 mile from the runway. before it impacted the ground, and collided with the airport's chain-link perimeter fence. The airplane came to rest upright just north of the runway threshold on a heading of 35°. A postimpact fire consumed most of the wreckage; however, all major components of the airplane were accounted for at the accident site.

Flight control continuity was established from all flight controls to the cockpit area. The flaps were in the fully retracted position and the fuel selector was set to the right tank.

The engine remained secured to the airframe and the engine cowling had burned away. The engine-driven fuel pump remained attached to the engine but was destroyed by fire. Both magnetos remained attached to the accessory housing. The left and right magnetos and their associated ignition harnesses were destroyed by fire and could not be tested.

Fuel lines, including the firewall-mounted fuel strainer, from the wings to the carburetor were destroyed by fire. The carburetor was thermally damaged and removed from the engine. The carburetor, which was equipped with composite floats, was disassembled and the bowl was empty. The inlet fuel screen was absent of debris.

The engine, with the propeller still attached, was removed from the airframe and examined. The top spark plugs and the rocker covers were removed. The spark plugs displayed a low service life and a color consistent with normal combustion per the Champion Check-a-Plug chart. The No. 2 cylinder bottom spark plug could not be removed due to the deformation of the exhaust header pipe. The No. 4 cylinder bottom spark plug had dislodged from the cylinder and was not recovered.

The engine was manually rotated via the propeller. Compression and valve train continuity was established for all but the No. 4 cylinder. The cylinder was removed and the exhaust valve was found seized in the valve guide in the open position; the valve face exhibited some deformation. The valve and the face of the piston displayed a substantial amount of carbon deposits. The No. 4 cylinder barrel bore also appeared worn and the piston rings were heat-compressed in the ring lands.

Medical And Pathological Information

The District 14 Medical Examiner, Panama City, Florida, performed an autopsy of the pilot. The cause of death was determined to be "airplane crash."

The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicology testing on specimens of the pilot. The results were negative for carbon monoxide, ethanol, and all tested-for drugs. Friends of the pilot reported that the pilot was diabetic and was having issues controlling his blood glucose. Additional testing revealed that glucose at 18 mg/dl in vitreous, 22 mg/dl in urine, and a hemoglobin A1C of 8.2%.

After death, "normal" glucose levels in vitreous are below 200 mg/dl. Levels below 150 mg/dl are normal in urine. Hemoglobin A1C is a measure of the percentage of hemoglobin molecules that have a glucose molecule attached to them. It is used as a measure of average blood glucose over the preceding several weeks. Non-diabetic levels are below 5.4%. Between 5.5% and 6.4% is considered "pre-diabetes" and above 6.5% indicates diabetes. For diabetic individuals, levels below 7.0% are considered "good control." Levels above 9% are considered "poor control."

Additional Information

Valve sticking in Lycoming reciprocating aircraft engines is addressed in Lycoming Mandatory Service Bulletin 388C and Lycoming Service Instruction 1485A. Mandatory Service Bulletin 388C, which, according to FAA regulations, is not mandatory for aircraft operated under 14 CFR Part 91, calls for all Lycoming reciprocating aircraft engines to be inspected at 400-hour intervals or earlier if valve sticking is suspected. If the valve and guide do not pass the inspection, then corrective action is to be taken as defined in Service Instruction 1485A. Once the guides are replaced with the newer Hi-Chrome guides, inspection is called for every 1,000 hours, half of the published TBO, or when valve sticking is suspected, whichever occurs first.

Review of the airplane maintenance logs revealed that the valve guides and stems had not been inspected in accordance with Lycoming Mandatory Service Bulletin 388C at the recommended 400-hour interval.