Wednesday, March 20, 2019

Fire / Smoke (Non-Impact): Beechcraft 35-A33 Debonair, N486T, fatal accident occurred May 12, 2018 in Jacksonville, Calhoun County, Alabama

Stefanie Amanda Smith Fasselin

Stefanie  started with Delta Air Lines in 2009 as a gate agent in Atlanta, but worked her way up through the Company. She was promoted to Strategic Communications Manager at Atlanta Airport World Port. She loved learning about the business world. She was a hard worker and an independent thinker. 



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 Aircraft; Wichita, Kansas
Continental Motors; Mobile, 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/N486T




Location: Jacksonville, AL
Accident Number: ERA18FA146
Date & Time: 05/12/2018, 2005 CDT
Registration: N486T
Aircraft: BEECH 35A33
Aircraft Damage: Destroyed
Defining Event: Fire/smoke (non-impact)
Injuries: 1 Fatal, 1 Serious
Flight Conducted Under: Part 91: General Aviation - Personal 

Analysis

The airline transport pilot and his daughter were on the return leg of a cross-country flight in night, visual meteorological conditions. While in cruise flight, the pilot saw smoke in the cockpit, so he began turning off electrical components. The engine then sputtered and lost total power. He set up for a forced landing, felt heat from the engine compartment, and then saw flames coming from the same area. He discharged a portable fire extinguisher. At the first indication of heat, his daughter left the right cockpit seat and climbed into the aft cabin; the pilot did not believe she fastened her lap belt. While crossing a ridge, the airplane collided with trees and came to rest on the side of a hill in a forested area. The pilot egressed the airplane and noted that his daughter was no longer in the airplane. He subsequently found her; she had been thrown clear of the wreckage and was seriously injured. First responders arrived soon thereafter, and she later died from her injuries.

Most of the airplane's fuselage, empennage, and right wing was consumed by postcrash fire. The left wing separated during the impact sequence and was not burned. The engine, propeller, nose landing gear, and cowling separated during the impact sequence and were found outside the postcrash fire zone. Evidence of an in-flight fire was observed at the aft section of the engine, with the heaviest fire damage near fuel lines adjacent to the left muffler and heat exchanger. An examination of the muffler and heat exchanger revealed multiple preexisting cracks that could have allowed hot exhaust gasses to escape from the assembly onto the adjacent fuel lines. Damage to those fuel lines prevented determining a definitive origin for the ignition of the inflight fire, though the damage to those fuel lines was consistent with the fire being fuel-fed in nature. The largest crack of the muffler was located at the left side and extended 3.35 inches around the circumference through the muffler wall and coincided with a crack through the heat exchanger end flange that extended 4.25 inches around the circumference. Oxidation and exhaust deposits observed on the crack surfaces indicated the cracks developed and existed for some time before the accident.

The pilot, who owned the airplane, was a certificated airframe and powerplant mechanic with inspection authorization. He performed the airplane's most recent annual and 100-hour inspections about 4 months before the accident. The airplane maintenance manual recommended that, during 100-hour inspections, the exhaust system should be checked for, in part, deformation and cracks and for thin wall condition, which may occur due to normal internal erosion on stacks that have long service time. About 2 months before the accident, the pilot replaced the left exhaust stack; however, he did not replace the associated muffler and heat exchanger.

The cracking observed on the muffler and heat exchanger displayed signatures consistent with them having developed over time, so the pilot should have been able to detect them by thoroughly inspecting the exhaust system, including the left muffler and heat exchanger, during the most recent 100-hour inspection as recommended, or when he removed and replaced the exhaust stack. Due to his inadequate inspection of the exhaust system, he failed to note the cracks and corrosion and missed an opportunity to replace the muffler and heat exchanger. This allowed the cracks to develop to failure, leading to hot gasses escaping on to the adjacent fuel lines, and ultimately resulting in the subsequent in-flight fire.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot/mechanic's inadequate inspection of the exhaust system, including the left muffler and heat exchanger, which precluded his detection of preexisting cracks and led to a missed opportunity to replace the components. The inadequate inspection allowed the cracks to develop to failure, leading to exhaust gasses escaping onto adjacent fuel lines, resulting in the subsequent fuel-fed in-flight fire. 

Findings

Aircraft
Noise suppressor - Inadequate inspection (Cause)
Engine exhaust - Inadequate inspection (Cause)
Engine exhaust - Fatigue/wear/corrosion (Cause)

Personnel issues
Scheduled/routine inspection - Pilot (Cause)
Scheduled/routine inspection - Maintenance personnel (Cause)
Forgotten action/omission - Passenger

Factual Information

History of Flight

Prior to flight
Aircraft maintenance event

Enroute-cruise
Fire/smoke (non-impact) (Defining event)
Loss of engine power (partial)

Emergency descent
Off-field or emergency landing
Collision with terr/obj (non-CFIT)

On May 12, 2018, about 2005 central daylight time, a Beech 35-A33 airplane, N486T, collided with trees and terrain during a forced landing near Jacksonville, Alabama. The airline transport pilot was seriously injured, and the passenger was fatally injured. The airplane was destroyed. The airplane was registered to the pilot who was operating it as a Title 14 Code of Federal Regulations Part 91 personal flight. Night, visual meteorological conditions prevailed near the accident site, and no flight plan was filed. The flight originated from Hartselle-Morgan County Regional Airport (5M0), Hartselle, Alabama, about 1924, and was destined for Falcon Field (FFC), Peachtree City, Georgia.

The pilot reported that he was familiar with the route from 5M0 to FFC and had previously flown it numerous times. He added that visual meteorological conditions prevailed and that he planned the route at 5,500 ft mean sea level. All ground operations and the departure from 5M0 were uneventful.

The pilot stated that his first indication of a problem was the smell of smoke. He was not immediately sure that it was coming from the airplane; he thought that it could have been coming from outside. However, he continued to smell the smoke and started turning off electrical equipment to determine the source. The flight kept progressing as the pilot analyzed the situation. He stated that the engine suddenly "sputtered and quit" just after the airplane crossed over the boundary of the Talladega National Forest, so he reversed course because it "appeared darker there." He then turned the fuel boost pump on and established the airplane's best glide airspeed. He believed at this point that the engine may have recovered some power and noted that the propeller was windmilling. He stated that he maneuvered the airplane toward a pasture and that, although it was night he could still see the ground.

The pilot stated that, after setting up the glide to a general area, he felt "heat." The passenger, who was his daughter, then climbed into the rear cabin. He did not believe that she fastened her lap belt after going to the aft seat. He saw flames coming from the engine compartment and discharged a fire extinguisher. The smoke continued and got heavy, so he opened the side window to clear the smoke so that he could see. The flames persisted. While crossing a ridge, the airplane struck trees, spun around, and then crashed. He was still inside the airplane, but his daughter was not. The wreckage was on fire. He egressed the cockpit and ran clear of the wreckage. He found his daughter, and she was injured. Shortly thereafter, first responders arrived. The fire eventually subsided and burned itself out.

A witness, who was outside of his home, stated that, about 2002 on the night of the accident, he saw what he thought was a single-engine airplane fly overhead traveling westbound. He added that the engine was "misfiring" and that he saw a "ball of light" and that the ball of light then "got bigger." Although he did not see any smoke coming from the airplane, it was getting dark at the time. He did not observe the crash. 

Pilot Information

Certificate: Airline Transport; Flight Instructor
Age: 52, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: Lap Only
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): Airplane Multi-engine; Airplane Single-engine
Toxicology Performed: No
Medical Certification: Class 1 With Waivers/Limitations
Last FAA Medical Exam: 07/05/2017
Occupational Pilot: No
Last Flight Review or Equivalent: 05/23/2017
Flight Time:  3360 hours (Total, all aircraft), 65 hours (Total, this make and model), 3360 hours (Pilot In Command, all aircraft), 24 hours (Last 90 days, all aircraft), 5 hours (Last 30 days, all aircraft)

The pilot held an airline transport pilot certificate with airplane single- and multiengine land ratings. He also held flight and ground instructor certificates. He reported 3,360 hours total flight experience, including 65 hours in Beech 35 airplanes. He was also an airframe and powerplant mechanic with inspection authorization and performed the maintenance on the airplane, including the annual inspections, preventive maintenance, and repairs. 

Aircraft and Owner/Operator Information

Aircraft Make: BEECH
Registration: N486T
Model/Series: 35A33 NO SERIES
Aircraft Category: Airplane
Year of Manufacture: 1961
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: CD-311
Landing Gear Type: Retractable - Tricycle
Seats: 4
Date/Type of Last Inspection: 01/15/2018, Annual
Certified Max Gross Wt.: 3000 lbs
Time Since Last Inspection: 12 Hours
Engines: 1 Reciprocating
Airframe Total Time: 5326 Hours as of last inspection
Engine Manufacturer: Continental
ELT: C91  installed, not activated
Engine Model/Series: IO-470-K
Registered Owner: On file
Rated Power: 225 hp
Operator: On file
Operating Certificate(s) Held: None 

The low-wing, single-engine, four-seat, retractable tricycle landing gear-equipped airplane was manufactured in 1961. It was powered by a Continental IO-470-K, 225-horsepower reciprocating engine equipped with a Hartzell constant-speed propeller. The pilot purchased the airplane in October 2015.

The pilot completed annual and 100-hr inspections of the airframe and engine on January 15, 2018, at 5,326.5 hours total aircraft time. A review of the airplane's maintenance log entries revealed no entries referencing any exhaust system components or indicating that any were replaced at this time. On March 20, 2018, at 5,329.3 hours total aircraft time, the pilot removed and replaced the left exhaust stack. He did not replace the left heat exchanger.

The Beech 35-A33 Maintenance Manual, under "Periodic Inspections," included the following step to be accomplished during 100-hr inspections:

24 – EXHAUST SYSTEM – Check for deformation, security, cracks, leaks, loose or missing nuts and clamps. Check for thin wall condition which may occur due to normal internal erosion on stacks which have long service time. 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Night
Observation Facility, Elevation: ANB, 612 ft msl
Distance from Accident Site: 14 Nautical Miles
Observation Time: 1953 CDT
Direction from Accident Site: 207°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: Calm /
Turbulence Type Forecast/Actual: / None
Wind Direction:
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 30.09 inches Hg
Temperature/Dew Point: 23°C / 17°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Hartselle, AL (5M0)
Type of Flight Plan Filed: None
Destination: Peachtree City, GA (FFC)
Type of Clearance: VFR Flight Following
Departure Time: 1924 CDT
Type of Airspace: Class G 

Anniston Regional Airport (ANB), Anniston, Alabama, located about 14 miles southwest of the accident site, reported, at 1953, wind calm, visibility 10 statute miles, sky clear, temperature 23°C, dew point 17°C, and altimeter setting 30.09 inches of mercury.

Official sunset at ANB occurred at 1934, about 31 minutes before the accident, and the end of civil twilight occurred at 2002. Moonset was at 1642. The moon was in a waning crescent phase with 10% of it illuminated. 

 Jacksonville Fire Chief Lee Batey and Calhoun County Coroner Pat Brown leave on a all-terrain vehicle to the crashed Beechcraft 35-A33 Debonair.

Wreckage and Impact Information

Crew Injuries: 1 Serious
Aircraft Damage: Destroyed
Passenger Injuries: 1 Fatal
Aircraft Fire: In-Flight and On-Ground
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal, 1 Serious
Latitude, Longitude: 33.798056, -85.725278 (est) 

The airplane crashed on the side of a hill in a forested area, about 2 miles southeast of the Jacksonville town center. The wreckage path was oriented on a westerly heading and was about 150 ft long. All the airplane components were accounted for at the accident site. The main wreckage consisted of the fuselage, empennage, and right wing. Most of the main wreckage, from the engine firewall aft, was consumed by postcrash fire. The left wing, which had separated during the impact sequence, was the first major airplane component found along the wreckage path about 65 ft east of the fuselage; it was not burned or soot-covered. All three landing gear were found in the retracted positions. The wing flaps were found retracted.

Flight control continuity was confirmed from all flight control surfaces to the cockpit controls. No residual fuel was found in the area of the wing fuel tanks. The fuel selector and fuel strainer were not located.

The engine, propeller, nose landing gear (NLG), and engine cowling separated during the impact sequence. The engine was found resting inverted against a tree about 15 ft from the main wreckage and postcrash fire site. The engine displayed black soot and heat damage on the aft accessory section. Several fuel lines were burned. The upper cowling, which was clear of the postcrash fire zone, displayed soot aft of the engine baffling, and there was brown discoloration and burned and blistered paint on the interior and exterior surfaces of the cowling. The NLG tire was burned on the surface closest to the engine.

An initial exterior examination of the engine revealed that the crankcase remained intact and displayed minor impact damage and significant thermal damage to the aft portion of the crankcase. The propeller flange remained attached to the rest of the crankshaft, and no visible cracks were noted in the crankshaft. All six cylinders displayed minor impact damage, and the Nos. 1 and 2 cylinders displayed minor soot discoloration at their aft sections. The exhaust system remained attached to the engine and displayed impact damage. The left exhaust muffler and heat exchanger assembly displayed several cracks in multiple locations.

The left and right magnetos remained attached at their installation points and displayed minor impact damage, and no thermal damage was noted. During manual crankshaft rotation, the impulse couplings operated normally. Both magnetos created a spark to each ignition lead in the correct order.

The ignition leads remained attached to the magnetos and spark plugs. Several of the ignition leads displayed impact damage, were partially severed, and exhibited no signs of thermal damage. No anomalies were noted with the ignition harness.

All the spark plugs remained in their cylinders. The top spark plugs were removed, and the electrodes displayed normal operating and wear signatures when compared to a Champion Check-A-Plug chart. The bottom spark plugs were inspected using a lighted borescope. The No. 1 spark plug was oil-soaked; the other electrodes displayed normal operating and wear signatures.

The engine-driven fuel pump remained attached at its installation point and displayed thermal damage. The fuel inlet fitting was found loose and was about 90° of turn from tight; the vapor return, fuel pump outlet, and mixture return fittings were all tight. The vapor return fuel line displayed thermal damage, and the hose was destroyed. The fuel pump inlet fuel line displayed thermal damage, and most of the fuel line was destroyed by fire. The fuel pump outlet and mixture return fuel lines displayed thermal damage near the fittings at the fuel pump. The heaviest areas of heat and fire damage to the fuel lines were adjacent to the left muffler and heat exchanger.

The engine-driven fuel pump was removed, and the pump drive was intact and capable of rotation. After removal, 100LL aviation fuel was poured into the fuel pump inlet with the inlet fitting set at the position as found at the recovery facility. Fuel leaked from the fitting as well as multiple locations along the thermally damaged fuel line. After fuel was poured into the pump, the pump drive was rotated by hand, and it was capable of pumping the residual fuel.

The throttle and metering assembly remained attached at its installation point and displayed impact damage; no thermal damage was noted. All the fuel lines were found secured. The fuel inlet screen was removed, and it was clear of any contaminants or obstructions. The fuel manifold valve remained attached at its installation point and displayed minor impact damage; no thermal damage was noted. All the fuel lines were found secured. The manifold valve was disassembled, and the internal components exhibited normal operating signatures. All fuel nozzles were installed in their respective cylinders and were undamaged. All the fuel lines supplying the fuel nozzles were found secured.

All the cylinders were inspected using a lighted borescope. The piston faces, cylinder bores, and valve heads displayed normal operating and combustion signatures. The overhead components (valve, springs, and rocker arms) displayed normal operating and lubrication signatures. During manual crankshaft rotation, all the cylinders displayed compression and suction using the "thumb" method. Continuity was established between the crankshaft, camshaft, connecting rods, and associated components.

The crankcase remained intact and displayed minor impact damage. The aft portion of the engine displayed thermal discoloration and soot. No signs of oil leaks were found around the crankcase. The oil screen remained installed and was secure. The screen was removed, and no metallic material was present.

The two-blade, constant-speed propeller remained attached to the crankshaft and displayed impact damage. Both propeller blades remained within the propeller hub. One of the propeller blades displayed minor twisting deformation at the propeller blade tip, and a portion of the tip was sheared from the rest of the blade. The other propeller blade displayed minor damage, and no bending or twisting deformation was noted.

Metallurgical examination of the muffler and heat exchanger revealed cracks in multiple locations in the left muffler and heat exchanger, including (1) at the forward left side of the assembly where the muffler end face was displaced forward at the outer circumference, exposing a crack opening from the interior to the exterior of the muffler and heat exchanger,(2) in the mufflers forward and aft end faces, adjacent to welds for internal baffles attached to the end face next to the exhaust stack attachment, and (3) through the aft heat exchanger end flange. Fracture features were generally covered with oxides and exhaust deposits across the thickness of the fracture. Near the ends of the muffler wall crack, light gray fracture features were observed, consistent with a relatively recent overstress fracture. The through-thickness oxidized portion of the crack in the muffler wall was 3.35 inches long circumferentially, and the wall crack was co-located with a 4.5-inch long oxidized crack through the heat exchanger end flange.

In a mounted and polished metallurgical section through the muffler wall crack location, the muffler wall aft of the fracture showed significant thickness variations associated with oxidation, and in one area aft of the crack, the wall was corroded nearly through the thickness in the plane of polish. The muffler wall showed branching intergranular cracks through the thickness at the fracture surface and through much of the thickness in areas forward of the fracture. Branching intergranular cracks were also observed on, and adjacent to, the fracture through the heat exchanger forward end flange.

The muffler had four cracks through the end faces, and each crack was approximately 0.8 inch to 0.9 inch long. Three of the cracks were through the aft end face, and one crack was through the forward end face. Some cracks were displaced open, and the fracture features on the opened cracks had fracture features that appeared to be covered with oxidation and exhaust deposits.

Two cracks were present at the aft end of the heat exchanger. A crack through the aft end flange at the upper side of the assembly was 4.25 inches long and was not associated with deformation to the aft end flange. A second crack in a deformed portion of the aft end flange had oxidized features through the thickness along a length of 2.25 inches.


For additional information regarding the examination of the muffler and heat exchanger, see the NTSB Materials Laboratory Factual Report, located in the public docket for this investigation.

Location: Jacksonville, AL
Accident Number: ERA18FA146
Date & Time: 05/12/2018, 2005 CDT
Registration: N486T
Aircraft: BEECH 35A33
Injuries: 1 Fatal, 1 Serious
Flight Conducted Under: Part 91: General Aviation - Personal 

On May 12, 2018, about 2005 central daylight time, a Beech 35-A33, N486T, collided with trees and terrain during a forced landing at in Jacksonville, Alabama. The airplane was destroyed. The airline transport pilot was seriously injured, and one passenger, his daughter, was fatally injured. The airplane was registered to the pilot and was operated under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Night, visual meteorological conditions prevailed, and no flight plan was filed for the flight. The flight originated at Hartselle-Morgan County Regional Airport (5M0), Hartselle, Alabama about 1924 and was destined for Falcon Field (FFC), Peachtree City, Georgia.

The pilot reported the following. He was familiar with the route from 5M0 to FFC and had flown it numerous times before. Visual meteorological conditions prevailed, and he planned the route at 5,500 ft mean sea level. All ground operations and the departure from 5M0 were uneventful.

His first indication of a problem was the smell of smoke. He was not completely sure it was from the airplane at first; he thought it could have been from outside. He continued to smell the smoke and "started turning stuff off." He kept progressing and analyzing the situation. The engine suddenly "sputtered and quit." He had just crossed over the boundary of the Talladega National Forest, so he reversed his course because it "appeared darker there." He turned the fuel boost pump on and established the airplane's best glide airspeed. He believed that the airplane may have recovered some power, and the engine was wind milling. He maneuvered the airplane toward a pasture near Jacksonville. It was night, VFR but he could still see the ground.

After setting up the glide to a general area, he felt a "warm heat." The passenger, who was his daughter, climbed into the rear cabin. He pulled out the fire extinguisher and shot discharged it toward the firewall where there were now flames. He had "some luck" with the extinguisher. The smoke continued and got heavy; he had to open the side window to let some air in, so he could clear the smoke and see. The flames persisted. While crossing a ridge, the airplane hit trees and spun around and crashed. He was still in the airplane, but his daughter was not. The wreckage was on fire. He egressed the cockpit, and ran clear of the wreckage. He found his daughter and she was injured. He could hear a siren "right away." First responders arrived shortly thereafter. The fire eventually died down subsided and burned itself out. There was no explosion.

The airplane crashed on the side of a hill in a forested area, about 2 miles southeast of the Jacksonville town center. The wreckage path was oriented on a westerly heading and was about 150 feet in length. All components of the airplane were accounted for at the accident site. Flight control continuity was confirmed from all flight control surfaces to the cockpit controls. The main wreckage consisted of the fuselage, empennage, and right wing. A majority of the main wreckage was consumed in the postcrash fire. The engine, propeller, nose landing gear, and engine cowling separated during the impact sequence and were found in an area free of post impact fire signatures. The engine displayed black soot and heat damage on the aft accessory section of the engine. Several fuel lines were burned. The upper cowling, which was clear of the postcrash fire zone, displayed soot aft of the engine baffling and there was brown discoloration and burned paint on the exterior surfaces of the cowling. The nose gear tire was burned on the surface closest to the engine.

The pilot held an airline transport pilot certificate with ratings for airplane multi-engine and single engine land privileges. He also held flight and ground instructor certificates. He reported 3,240 hours total flight time on his latest Federal Aviation Administration first class medical certificate, dated July 5, 2017. He was an airframe and powerplant mechanic with an inspection authorization authority and performed the maintenance on the airplane, including the annual inspections.

The low-wing, single-engine, four-seat airplane incorporated a retractable, tricycle landing gear. The airplane was equipped with a Continental IO-470-K, 225-horsepower reciprocating engine . The engine was fitted with a Hartzell constant -speed propeller. The airplane was built manufactured in 1961. The pilot reported that the maintenance records were at his residence and would provide them to the investigation team.

The wreckage was retained for further examination 

Aircraft and Owner/Operator Information

Aircraft Manufacturer: BEECH
Registration: N486T
Model/Series: 35A33 NO SERIES
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: Night
Observation Facility, Elevation: ANB, 612 ft msl
Observation Time: 1953 CDT
Distance from Accident Site: 14 Nautical Miles
Temperature/Dew Point: 23°C / 17°C
Lowest Cloud Condition: Clear
Wind Speed/Gusts, Direction: Calm
Lowest Ceiling: None
Visibility: 10 Miles
Altimeter Setting: 30.09 inches Hg
Type of Flight Plan Filed: None
Departure Point: Hartselle, AL (5M0)
Destination: Peachtree City, GA (FFC)

Wreckage and Impact Information

Crew Injuries: 1 Serious
Aircraft Damage: Destroyed
Passenger Injuries: 1 Fatal
Aircraft Fire: Both
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal, 1 Serious
Latitude, Longitude: 33.798056, -85.725278 (est)

Loss of Engine Power (Total): Piper PA-28R-200, N9431N; accident occurred August 20, 2017 near Northeast Florida Regional Airport (KSGJ), St. Augustine, St. Johns 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, Florida

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/N9431N



Location: St. Augustine, FL
Accident Number: ERA17LA300
Date & Time: 08/20/2017, 1120 EDT
Registration: N9431N
Aircraft: PIPER PA 28R-200
Aircraft Damage: Substantial
Defining Event: Loss of engine power (total)
Injuries: 2 Minor
Flight Conducted Under: Part 91: General Aviation - Instructional 

Analysis 

The flight instructor reported that, during a training flight to practice touch-and-go landings, while the airplane was climbing through 500 ft, the engine started to "sputter." The student pilot, who was flying the airplane, stated that she switched the fuel tanks just before the engine lost power but that she was unsure which tank she had selected. Due to the low altitude, the flight instructor took control of the airplane and performed an emergency landing in a marsh, during which the right wing and airframe sustained substantial damage.

An examination of the airplane and engine did not reveal evidence any preimpact mechanical malfunctions or failures that would have precluded normal operation. Before takeoff, the airplane had 25 gallons of fuel onboard, and the airplane had been flown about 1 hour before the engine lost power. According to the engine operating manual, the engine's fuel consumption rate was 12.5 gallons per hour, which would have resulted in about half of the fuel supply still being available when the engine lost power, assuming that the supply of fuel in the selected fuel tank had not already been exhausted. However, the postaccident quantity of fuel onboard the airplane could not be verified due to the airplane having rested in the marsh after the accident. Therefore, based on the available evidence, the reason for the loss of engine power could not be determined. 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
A total loss of engine power for reasons that could not be determined because examination of the airplane and engine did not reveal evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation and because the amount of fuel onboard the airplane could not be verified. 

Findings

Not determined
Not determined - Unknown/Not determined (Cause)

Factual Information

On August 20, 2017, about 1120 eastern daylight time, a Piper PA-28R-200, N9431N, was substantially damaged during a forced landing after takeoff from Northeast Florida Regional Airport (SGJ) St Augustine, Florida. The flight instructor and student pilot sustained minor injuries. The airplane was privately owned, and the instructional flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed at the time, and no flight plan was filed for the local flight, which originated from SGJ about 1035.

According to the flight instructor, the purpose of the flight was to practice traffic pattern touch-and-go landings. The instructor said that during the run-up he told the student "not to forget to change the fuel tanks every 30 minutes." The flight instructor stated that they were on their fourth takeoff and were climbing through 500 ft when the engine started to "sputter." The flight instructor took control of the airplane, declared an emergency and landed the airplane in a marsh area.

According to the student pilot, as they were climbing through 500 ft, she switched the fuel tanks while climbing and the engine "failed." The student pilot did not recall which fuel tank she switchd to prior to the loss of engine power. She passed the controls over to the instructor to perform the emergency landing.

Examination of the airplane by a Federal Aviation Administration Inspector revealed the right wing and airframe was buckled. A cursory examination of the engine did not reveal any anomalies that would have precluded normal operation. Due to the airplane resting in the marsh the amount of fuel remaining in the wing tanks could not be determined. Prior to take off the airplane had a total of 25 gallons of fuel on board. According to the Lycoming engine operator's manual, the IO-360C series engine fuel consumption is 12.5 gallons per hour at performance cruise. The airplane was flown for about an hour prior to the loss of engine power.

History of Flight

Initial climb
Loss of engine power (total) (Defining event)

Landing
Off-field or emergency landing



Flight Instructor Information

Certificate: Flight Instructor; Commercial
Age: 25, 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 Multi-engine; Airplane Single-engine
Toxicology Performed: No
Medical Certification: Class 2 Without Waivers/Limitations
Last FAA Medical Exam: 01/21/2015
Occupational Pilot: Yes
Last Flight Review or Equivalent: 05/17/2017
Flight Time:  1340 hours (Total, all aircraft), 4 hours (Total, this make and model), 1267 hours (Pilot In Command, all aircraft), 336 hours (Last 90 days, all aircraft), 122 hours (Last 30 days, all aircraft), 6 hours (Last 24 hours, all aircraft) 



Pilot Information

Certificate: Private
Age: 20, Female
Airplane Rating(s): 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): None
Toxicology Performed: No
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 10/31/2016
Occupational Pilot: Yes
Last Flight Review or Equivalent: 07/02/2017
Flight Time:  (Estimated) 228 hours (Total, all aircraft), 3 hours (Total, this make and model), 167 hours (Pilot In Command, all aircraft), 48 hours (Last 90 days, all aircraft), 17 hours (Last 30 days, all aircraft)



Aircraft and Owner/Operator Information

Aircraft Make: PIPER
Registration: N9431N
Model/Series: PA 28R-200 200
Aircraft Category: Airplane
Year of Manufacture: 1969
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 28R-35144
Landing Gear Type: Retractable - Tricycle
Seats: 4
Date/Type of Last Inspection: 05/19/2017, Annual
Certified Max Gross Wt.: 2150 lbs
Time Since Last Inspection: 60 Hours
Engines: 1 Reciprocating
Airframe Total Time: 6942.8 Hours as of last inspection
Engine Manufacturer: LYCOMING
ELT: C91  installed, not activated
Engine Model/Series: I0360 SER
Registered Owner: MARTIN ROBERT S
Rated Power: 200 hp
Operator: On file
Operating Certificate(s) Held: None



Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: SGJ, 10 ft msl
Distance from Accident Site: 0 Nautical Miles
Observation Time: 1056 EDT
Direction from Accident Site: 0°
Lowest Cloud Condition: Few / 2700 ft agl
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: Calm /
Turbulence Type Forecast/Actual: /
Wind Direction:
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 30.08 inches Hg
Temperature/Dew Point: 31°C / 25°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: St. Augustine, FL (SGJ)
Type of Flight Plan Filed: None
Destination: St. Augustine, FL (SGJ)
Type of Clearance: None
Departure Time: 1035 EDT
Type of Airspace: Class D

Airport Information

Airport: NORTHEAST FLORIDA RGNL (SGJ)
Runway Surface Type: Asphalt
Airport Elevation: 9 ft
Runway Surface Condition: Vegetation; Water--calm
Runway Used: 13
IFR Approach: None
Runway Length/Width: 8002 ft / 150 ft
VFR Approach/Landing: Forced Landing

Wreckage and Impact Information

Crew Injuries: 2 Minor
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Minor
Latitude, Longitude: 29.959167, -81.339722 (est)

Loss of Control on Ground: Cessna 195, N2100C; accident occurred August 10, 2017 at Newnan–Coweta County Airport (KCCO), Georgia

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

Additional Participating Entity:

Federal Aviation Administration / Flight Standards District Office; Atlanta, Georgia

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/N2100C


Location: Newman, GA
Accident Number: ERA17LA324
Date & Time: 08/10/2017, 1700 EDT
Registration: N2100C
Aircraft: CESSNA 195
Aircraft Damage: Substantial
Defining Event: Loss of control on ground
Injuries: 2 None
Flight Conducted Under: Part 91: General Aviation - Personal

Analysis 

According to airline transport pilot, during the takeoff roll, the airplane veered left. The pilot tried to correct the turn without success, and the airplane subsequently departed the left side of the runway, struck a taxiway light, and then came to rest in grass adjacent to the runway. The airplane sustained substantial damage to the fuselage and right wing. The pilot reported that he had owned the airplane for about 1 month, during which time he observed that he had to continuously apply right rudder for the airplane to taxi straight ahead, which he thought was normal for that airplane.

Examination of the tailwheel assembly revealed that, when the rudder pedals were centered, the rudder was also centered. However, the tailwheel remained in a left-turn position and required about 75% right rudder input to center the tailwheel, and with full-right rudder deflection, the tailwheel turned very little to the right. A review of the maintenance records revealed that maintenance, including the installation of a new upper mount assembly and a new tailwheel strut, was performed on the tailwheel assembly about 3 years before the accident. Given the pilot's report that he had always needed to apply right rudder for the airplane to taxi straight ahead, it is likely that the tailwheel assembly was improperly rigged following the previous maintenance.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The improper rigging of the tailwheel assembly, which resulted in a loss of directional control during takeoff. Contributing to accident was the pilot's decision to operate the airplane despite knowing it required excessive right rudder inputs for it to move straight ahead.

Findings

Aircraft
Landing gear steering system - Incorrect service/maintenance (Cause)

Personnel issues
Decision making/judgment - Pilot (Factor)

Factual Information 

On August 10, 2017, about 1700 eastern daylight time, a Cessna 195, N2100C, was substantially damaged during takeoff from Newnan Coweta County Airport (CCO), Newnan, Georgia. The airline transport pilot and passenger were not injured. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the local flight.

According to the pilot, he taxied the airplane to the active runway for takeoff. During the takeoff roll, the airplane veered to the left. The pilot attempted to correct the turn but was unsuccessful. The airplane departed the left side of the runway, collided with a taxiway light and came to rest in the grass adjacent to the runway.

Examination of the airplane by a Federal Aviation administration (FAA) inspector revealed that the fuselage and the right wing was buckled. An examination of the rudder and tail wheel assembly revealed that when the rudder pedals were centered, the rudder was also centered. However, the tail wheel remained in a left turn position. It required approximately 75% right rudder input to center the tail wheel. With full right rudder deflection, there was very little right turn in the tail wheel.

Review of the airplane's maintenance logbooks revealed that maintenance was performed on tailwheel assembly, that included the installation of a new upper mount assembly with channel kit as well as an overhauled tailwheel strut in August 2014. The airplane accumulated 48.5 hours since that overhaul. The last annual inspection was completed on March 23, 2017.

During an interview the pilot stated that he purchased the airplane one month prior to the accident. He operated the airplane a total of about 12 hours, which included 15 landings. He received his tailwheel endorsement on July 27, 2017. He further stated that while taxiing, he had to "keep the rudder in" to taxi straight ahead, which he thought was a normal characteristic of the airplane.

History of Flight

Takeoff
Loss of control on ground (Defining event)
Attempted remediation/recovery
Runway excursion
Collision with terr/obj (non-CFIT)

Pilot Information

Certificate: Airline Transport
Age: 56, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 4-point
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): Airplane Single-engine
Toxicology Performed: No
Medical Certification: Class 1 With Waivers/Limitations
Last FAA Medical Exam: 03/03/2017
Occupational Pilot: Yes
Last Flight Review or Equivalent:
Flight Time:  (Estimated) 13000 hours (Total, all aircraft), 12 hours (Total, this make and model), 9600 hours (Pilot In Command, all aircraft), 12 hours (Last 90 days, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: CESSNA
Registration: N2100C
Model/Series: 195 UNDESIGNATED
Aircraft Category: Airplane
Year of Manufacture: 1953
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 16085
Landing Gear Type: Tailwheel
Seats: 5
Date/Type of Last Inspection: 09/30/2016, Annual
Certified Max Gross Wt.: 3350 lbs
Time Since Last Inspection: 15 Hours
Engines: 1 Reciprocating
Airframe Total Time: 2550 Hours as of last inspection
Engine Manufacturer: JACOBS
ELT: C91  installed, not activated
Engine Model/Series: R755A SERIES
Registered Owner: On file
Rated Power: 350 hp
Operator: On file
Operating Certificate(s) Held: None 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: cco, 970 ft msl
Distance from Accident Site:0 Nautical Miles
Observation Time: 1715 EDT
Direction from Accident Site: 0°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 5 knots /
Turbulence Type Forecast/Actual: /
Wind Direction: 150°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 30.1 inches Hg
Temperature/Dew Point: 30°C / 25°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Newman, GA (CCO)
Type of Flight Plan Filed: None
Destination: Newman, GA (CCO)
Type of Clearance: VFR
Departure Time: 1700 EDT
Type of Airspace: Class G

Airport Information

Airport: NEWNAN COWETA COUNTY (CCO)
Runway Surface Type: Asphalt
Airport Elevation: 970 ft
Runway Surface Condition: Dry
Runway Used: 14
IFR Approach: None
Runway Length/Width: 5500 ft / 100 ft
VFR Approach/Landing: None 

Wreckage and Impact Information

Crew Injuries: 1 None
Aircraft Damage: Substantial
Passenger Injuries: 1 None
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 None
Latitude, Longitude:  33.311667, -84.769722 (est)

Extra EA-300/L, owned by the pilot and operated under the provisions of Title 14 Code of Federal Regulations Part 91, N210MX: Fatal accident occurred July 13, 2017 in Winchester, Cheshire County, New Hampshire

John E. Everson

John was a licensed pilot with almost 3000 hours of flying time. At the time of his death, he was flying his Extra EA-300/L, a two-seat unlimited class aerobatic airplane, in which he had over 1000 hours of flying time. John's fascination with flying began at a very early age due to the influence of his father's service in WWII as a combat fighter ace. At the age of 14, John began flying gliders which began his over 50 year love of flying that culminated in his most recent accomplishment of finishing 1st place in his skill class at a recent aerobatic competition. He is remembered as a man who loved his family, who valued hard work, with an undeniable passion for aviation.

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

Additional Participating Entity:

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

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


Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms 
 
http://registry.faa.gov/N210MX




Location: Winchester, NH
Accident Number: ERA17FA241
Date & Time: 07/13/2017, 1125 EDT
Registration: N210MX
Aircraft: EXTRA FLUGZEUGBAU GMBH EA 300/L
Aircraft Damage: Destroyed
Defining Event: VFR encounter with IMC
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

Analysis 

The noninstrument-rated private pilot was conducting a cross-country flight to compete in an aerobatic competition scheduled to begin the next day. Weather information showed that the pilot would have experienced increasingly cloudy conditions as the airplane proceeded along the route of flight. Radar data indicated that the airplane was flying on a northerly heading before it made two complete right turns followed by a larger diameter sweeping right turn, and abrupt and rapid diversions from the en route altitude. The last 3 minutes of data showed the airplane climbing from 2,000 ft mean sea level (msl) (1,300 ft above ground level) to 6,425 ft msl. The airplane then began to descend, and radar contact was lost at 5,800 ft msl. Automated observations from airports north and south of the accident site showed ceilings at 800 ft above ground level and 1,200 ft above ground level, respectively. The pilot did not obtain a weather briefing from an official, access-controlled source before departing on the flight, and it could not be determined if he checked or received additional weather information before or during the flight.

A witness described the airplane as performing "aerobatics" in a very "low cloud ceiling." He subsequently observed the airplane enter a "high vertical climb," and then heard it descending. The airplane descended through the bottom of the clouds and continued "straight down" until impact. In addition, a witness heard the engine operating at a high power setting before impact. The damage to adjacent trees and the limited linear wreckage debris path were consistent with a near-vertical, nose-low attitude at impact. Examination of the airframe and engine did not reveal any evidence of a preimpact anomaly or malfunction. A placard in the airplane stated that the airplane was not approved for flight in instrument meteorological conditions.

Despite not being instrument rated and flying an airplane that was not certificated for instrument conditions, the pilot chose to continue along the flight route as weather conditions deteriorated rather than diverting, consistent with a common behavioral trap known as "get-there-it is." It is likely that the pilot's desire to get to the destination airport in order to prepare for the competition contributed to this behavior. The instrument meteorological conditions that existed in the area of the accident site around the accident time and the airplane's turning ground track and near-vertical descent were consistent with a loss of control due to spatial disorientation.

Toxicology testing identified THC and its primary metabolite in liver, kidney, and lung specimens. While this indicated that the pilot had used marijuana at some point before the flight, without results from a blood specimen, it could not be determined when he used it or whether it may have had impairing effects at the time of the accident.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The noninstrument-rated pilot's continued visual flight rules flight into instrument meteorological conditions, which resulted in spatial disorientation and collision with terrain. Contributing to the accident was the pilot's self-induced pressure to complete the flight in order to attend the aerobatic competition. 

Findings

Aircraft
Performance/control parameters - Not attained/maintained (Cause)

Personnel issues
Spatial disorientation - Pilot (Cause)
Aircraft control - Pilot (Cause)
Motivation/respond to pressure - Pilot (Factor)
Use of medication/drugs - Pilot

Environmental issues
Below VFR minima - Effect on operation (Cause)

Factual Information

History of Flight

Enroute-cruise
VFR encounter with IMC (Defining event)

Enroute
Loss of control in flight

Uncontrolled descent
Collision with terr/obj (non-CFIT)

On July 13, 2017, about 1125 eastern daylight time, an Extra Flugzeugbau GMBH EA 300/L, N210MX, was destroyed after it impacted trees and terrain near Winchester, New Hampshire. The private pilot was fatally injured. The airplane was owned by the pilot who operated it under the provisions of Title 14 Code of Federal Regulations Part 91. Instrument meteorological conditions prevailed, and no flight plan was filed for the personal flight, which originated about 1030 from Danielson Airport (LZD), Danielson, Connecticut, and was destined for Hartness State Airport (VSF), Springfield, Vermont.

According to the pilot's son, the pilot was flying to VSF to compete in an aerobatic competition being held that weekend. The pilot would typically fly to the competition airport on a Thursday morning in order to practice in the aerobatic box that afternoon. The competition would take place on Friday and Saturday.

A review of radar data provided by the Federal Aviation Administration (FAA) indicated that the airplane was flying on a northerly heading before it made two complete right turns, followed by a larger diameter sweeping right turn, and abrupt and rapid diversions from the en route altitude. The last 3 minutes of data indicated that the airplane climbed from 2,000 ft mean sea level (msl) (about 1,300 ft above ground level) to 6,425 ft msl. The airplane then began to descend, and radar contact was lost at 5,800 ft msl, about 35 miles from the destination airport.

A witness heard the airplane and went into a field to watch it. He described the airplane performing "aerobatics" in a very "low cloud ceiling." Several minutes after he began watching the airplane, it descended "so low" that he and his son began waving at it. Then, about 1125, the airplane "went into a high vertical climb," and climbed to an altitude at which the witness could barely hear it. The witness then heard the airplane descending. He watched it descend through the bottom of the clouds and continue "straight down," then heard the sound of impact. He stated that the time between the airplane's descent out of the clouds and impact was about "2 to 3 seconds." Another witness reported hearing the airplane's engine before the accident and reported that it sounded like "it was racing," and that the "rpms were high."



Pilot Information

Certificate: Private
Age: 65, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Rear
Other Aircraft Rating(s): None
Restraint Used: 4-point
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 10/19/2016
Occupational Pilot: No
Last Flight Review or Equivalent: 09/16/2015
Flight Time: 2810 hours (Total, all aircraft) 

According to FAA records, the pilot held a private pilot certificate with a rating for airplane single-engine land. The pilot was issued a third-class FAA medical certificate on October 19, 2016, with the limitation that he must wear corrective lenses. At that time, he reported 2,810 total hours of flight experience and 108 hours during the previous 6 months. The pilot did not hold an instrument rating. 


Aircraft and Owner/Operator Information

Aircraft Make: EXTRA FLUGZEUGBAU GMBH
Registration: N210MX
Model/Series: EA 300/L
Aircraft Category: Airplane
Year of Manufacture: 2005
Amateur Built: No
Airworthiness Certificate: Aerobatic; Normal
Serial Number: 1210
Landing Gear Type: Tailwheel
Seats: 2
Date/Type of Last Inspection: 04/18/2017, Annual
Certified Max Gross Wt.:
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 956.57 Hours as of last inspection
Engine Manufacturer: LYCOMING
ELT: C91A installed, not activated
Engine Model/Series: AEIO-540-L1B5
Registered Owner: On file
Rated Power: 300 hp
Operator: On file
Operating Certificate(s) Held: None

According to FAA records, the two-place monoplane was manufactured in 2005 and was registered to the pilot in 2006. It was equipped with a Lycoming AEIO-540-L1B5 series, 300-horsepower engine that drove a four-bladed, constant speed, MT-Propeller. According to airplane maintenance records, an annual inspection was completed on April 18, 2017, at 956.57 total aircraft hours.

A placard located in the cockpit stated, "This airplane is certificated for VFR day operation." 



Meteorological Information and Flight Plan

Conditions at Accident Site: Instrument Conditions
Condition of Light: Day
Observation Facility, Elevation: ORE, 555 ft msl
Distance from Accident Site: 11 Nautical Miles
Observation Time: 1052 EDT
Direction from Accident Site: 160°
Lowest Cloud Condition: Thin Overcast / 800 ft agl
Visibility: 10 Miles
Lowest Ceiling: Overcast / 800 ft agl
Visibility (RVR):
Wind Speed/Gusts: 7 knots /
Turbulence Type Forecast/Actual: /
Wind Direction: 40°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 30 inches Hg
Temperature/Dew Point: 19°C / 18°C
Precipitation and Obscuration:  No Obscuration; No Precipitation
Departure Point: Danielson, CT (LZD)
Type of Flight Plan Filed: None
Destination: SPRINGFIELD, VT (VSF)
Type of Clearance: None
Departure Time: 1030 EDT
Type of Airspace: 

At 1052, the recorded weather observation at Orange Municipal Airport (ORE), Orange, Massachusetts, about 11 miles south of the accident site, included wind from 040° at 7 knots, visibility 10 miles, overcast clouds 800 ft above ground level (agl), temperature 19°C, dew point 18°C; and an altimeter setting of 30.00 inches of mercury.

At 1056, the recorded weather observation at Dillant-Hopkins Airport (EEN), Keene, New Hampshire, about 11 miles northeast of the accident location, included wind from 010° at 4 knots, 10 miles visibility, an overcast ceiling at 1,200 ft agl, temperature 16°C, dew point 14°C, and altimeter setting of 30.02 inches of mercury.

According to a NTSB Senior Meteorologist, the observations from ORE and EEN surrounding the accident time indicated instrument flight rules (IFR) to marginal visual flight rules (MVFR) ceiling conditions. With a northeast surface wind east of the Appalachian Mountains and a surface high pressure center in place over the northeastern United States, cold air damming (CAD) conditions were likely. The self-reinforcing CAD allowed for continued IFR ceilings north of the warm front at the accident site at the accident time.

In addition, a review of visible and infrared data from the Geostationary Operational Environmental Satellite number 13 (GOES-13) indicated abundant cloud cover above the accident site at the accident time. The cloud cover increased dramatically along the airplane's northerly route of flight. Infrared imagery indicated higher cloud tops located northeast through west of the accident site, with the highest cloud tops over New York. Based on the brightness temperatures above the accident site and the vertical temperature profile provided by the upper air data sounding, the approximate cloud-top heights over the accident site were 22,000 ft at 1115.

A search of official weather briefing sources revealed that the pilot did not contact Leidos or Direct User Access Terminal Service (DUATS) for weather information. An archive search of ForeFlight data revealed that the pilot did not gather weather information from ForeFlight before or during the accident flight. It is unknown if the pilot checked or received additional weather information before or during the accident flight.

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 42.739444, -72.386111 

Examination of the accident site revealed a strong odor of fuel. All major components of the airplane were accounted for at the scene. The main wreckage came to rest oriented on a 025° heading in a heavily wooded area at an elevation of 680 ft msl. Impact damage was observed on a 100-ft-tall tree that was consistent with the airplane impacting the tree before impacting the ground about 25 ft beyond the tree strike. There were a few branches between the tree strike and the main wreckage location that exhibited 45° cuts. In addition, chips of white paint were lodged in the wood. The main wreckage came to rest about 15 ft beyond the initial impact crater against two trees. The initial impact crater was about 4 ft deep and about 6 ft in diameter. Linear ground scars consistent with the length and dimension of the leading edge of each wing were visible on either side of the impact crater.

The cockpit was destroyed and fragmented by impact forces. The cockpit instrument panel was destroyed, and the flight and performance instruments were separated. No useful information was obtained from the instruments. The attitude indicator was not located and the turn coordinator face was destroyed. Flight control continuity was obtained from all flight control surfaces to the cockpit through breaks and fractures consistent with overload. The right wing was impact-separated and fractured. A majority of the pieces were located forward of the impact crater. The left wing was impact-separated and fractured. Several sections of the left wing and aileron were located aft of the initial impact crater.

The empennage remained attached to the fuselage. The left horizontal stabilizer and elevator remained attached to the empennage. The rudder remained attached to the vertical stabilizer and displayed impact damage along about 8 inches of its upper section. The right horizontal stabilizer was impact-separated but remained attached to the empennage by control cables. The right elevator was impact-separated and was located just aft of the right horizontal stabilizer. The elevator trim tab was impact-separated but remained attached to the right elevator through cables.

All four wooden propeller blades were impact-separated and fragmented. Several pieces of the propeller blades were located in the initial impact crater and a few pieces were located about 25 ft from the initial impact crater. The propeller hub remained attached to the crankshaft flange.

The engine came to rest upright, facing opposite the direction of travel. Three of the four engine mounts were impact-separated from the crankcase. Impact fractures were noted throughout the crankcase and sections were missing on the Nos. 1, 3, and 5-cylinder side. Cylinder No. 1 was impact-separated from the engine. Cylinder Nos. 3 and 5 were impact-separated from the crankcase but remained attached through the piston and connecting rods. The No. 2 cylinder head was impact-separated, and the Nos. 4 and 6 cylinders remained intact and attached to the crankcase. All cylinders exhibited impact damage on the cooling fins. The Nos. 3, 5, and 2 pistons were visible, and carbon deposits were noted on the piston faces. The crankshaft would not rotate; however, no fractures or thermal discoloration were noted. The camshaft remained intact and no anomalies were noted with the visible camshaft lobes. No thermal discoloration or damage was noted inside the engine crankcase.

A JPI EDM 700 engine monitor was retained and sent to the NTSB Recorders Laboratory for data download. The data indicated that the engine was operating throughout the flight without anomaly.

Medical And Pathological Information

The State of New Hampshire Office of the Chief Medical Examiner, Concord, New Hampshire performed the autopsy on the pilot. The autopsy report indicated that the pilot died as a result of multiple blunt impact injuries.

The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing of the pilot. Fluid and tissue specimens from the pilot tested negative for carbon monoxide. The test indicated 105 mg/dL of ethanol in the liver, but no ethanol in the kidney, which was consistent with postmortem production. The testing identified 0.2965 ug/ml of tetrahydrocannabinol (THC) in the lung and 0.366 ug/ml of THC in the kidney. In addition, 0.4511 ug/ml of 11-carboxytetrahydrocannabinol (THC-COOH) was detected in the kidney and 0.0766 ug/ml THC-OOH was detected in the lung.

THC is the primary psychoactive compound in marijuana and THC-COOH is the primary non-active metabolite of THC in liver tissue. 

Additional Information

FAA Advisory Circular (AC) 60-4A, "Pilot's Spatial Disorientation," states, in part:

The attitude of an aircraft is generally determined by reference to the natural horizon or other visual references with the surface. If neither horizon nor surface references exist, the attitude of an aircraft must be determined by artificial means from the flight instruments. Sight, supported by other senses, allows the pilot to maintain orientation. However, during periods of low visibility, the supporting senses sometimes conflict with what is seen. When this happens, a pilot is particularly vulnerable to disorientation. The degree of disorientation may vary considerably with individual pilots. Spatial disorientation to a pilot means simply the inability to tell which way is "up."

The AC notes that a disoriented pilot may place an aircraft in a dangerous attitude, and recommends that pilots, "not attempt visual flight rules flight when there is a possibility of getting trapped in deteriorating weather."

Get-There-Itis

According to FAA Advisory Circular AC 60-22, Aeronautical Decision Making, "pilots, particularly those with considerable experience, as a rule always try to complete a flight as planned, please passengers, meet schedules, and generally demonstrate that they have 'the right stuff.'"

One of the common behavioral traps identified was "Get-There-Itis." According to the AC, "common among pilots, [get-there-itis] clouds the vision and impairs judgment by causing a fixation on the original goal or destination combined with a total disregard for any alternative course of action."

Get-There-Itis is also known as hurry syndrome, plan continuation, or goal fixation.

Bradley Brewer, of 342 Manning Hill Road, in Winchester, New Hampshire, stands in the spot where he said he heard an aircraft go down around 11:30 a.m. on July 13th, 2017.

Kumaran Spaulding talks with emergency personnel about a plane crash at 375 Scotland Road, in Winchester, New Hampshire, around 11:30 a.m. on July 13th, 2017. Spaulding said he was out in the field with his son, Darian, when they heard the sound of an airplane engine throttling up and down, then saw the plane exiting the clouds going over the tree line. The father said he may have heard a crash; the son said the valley suddenly went silent. 


Dennis Croteau, of Walpole Rescue, from Walpole, New Hampshire, prepares a Typhoon H model drone at 375 Scotland Road, in Winchester, New Hampshire after witnesses said they saw the plane crash around 11:30 a.m. on July 13th, 2017.



Keene, N.H., Fire Department Lt. Aaron Cooper points while Lt. Raymond Phillips operates a DJI Phantom 3 Drone while searching the area for the Extra EA-300/L that had crashed.