Saturday, April 27, 2019

Ryan Navion B, personal flight conducted under the provisions of 14 Code of Federal Regulations Part 91, N5327K: Accident occurred September 27, 2016 in Hurt, Pittsylvania County, Virginia

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

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Richmond, Virginia
Continental Motors Inc; Mobile, Alabama 

Aviation Accident Factual 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/N5327K


Ron Natalie

Ron said he was flying to North Carolina in his Ryan Navion B when he noticed the oil leaking and the "engine seized." He said he had to make an emergency landing in a field in Hurt, Virginia.

Location: Hurt, VA
Accident Number: ERA16LA333
Date & Time: 09/27/2016, 1745 EDT
Registration: N5327K
Aircraft: RYAN NAVION
Aircraft Damage: Substantial
Defining Event: Powerplant sys/comp malf/fail
Injuries: 1 None
Flight Conducted Under: Part 91: General Aviation - Personal 

On September 27, 2016, about 1745 eastern daylight time, a Ryan Navion B, N5327K, was substantially damaged during a forced landing, following a total loss of engine power while in cruise flight near Hurt, Virginia. The private pilot was not injured. Visual meteorological conditions prevailed, and no flight plan was filed for the personal flight, which was conducted under the provisions of 14 Code of Federal Regulations Part 91. The flight departed Culpeper Regional Airport (CJR), Culpeper, Virginia, about 1700, destined for Long Island Airport (NC26), Long Island, North Carolina.

According to the pilot, about 45 minutes into the flight, at an altitude of 3,000 feet mean sea level, the engine suddenly began to vibrate. He informed Roanoke Approach air traffic control (ATC) of his intent to try to land at the nearest airport, which was New London Airport (W90), Forest, Virginia. A few seconds later he heard a loud bang, the vibration worsened, smoke and oil emanated from the engine compartment, and the engine lost power as the propeller continued to windmill. The pilot then advised ATC that he would not be able to make the airport, and he then performed an emergency landing to a mowed hay field. During the landing rollout, the airplane struck and rolled through a post-and-wire fence resulting in substantial damage to the right wing.

Examination of the airplane by a Federal Aviation Administration inspector revealed that the right wing leading edge sustained substantial damage, and fence wire was wrapped around the propeller flange. The top left side of the engine crankcase was damaged, and there were holes in the crankcase near cylinder Nos. 6, 4 and 2. A connecting rod protruded through the hole near cylinder No. 4. No oil was present in the crankcase. A teardown examination of the engine was subsequently performed at the manufacturer's facility, under the supervision of a National Transportation Safety Board investigator. The examination revealed that the internal engine components exhibited heat distress consistent with a lack of lubrication. Further examination revealed that the oil temperature probe was safety wired, however it could be moved by hand. An air pressure hose was attached to the oil cooler and when 30 psi was applied, bubbles were noted around the crush washer seal of the oil temperature probe. Oil residue was also noted all over the oil cooler and surrounding area of the engine. See Figure 1. The oil temperature probe was removed, and the crush washer was found installed backwards.


Figure 1. Oil Temperature Probe

The temperature probe was considered an airframe item and was not installed by the engine manufacturer. The engine was delivered with a plug in the oil temperature probe port, and the installer could remove the plug and replace it with an oil temperature probe. A review of the 1951 Navion B Service Manual revealed no specific torque values for tightening the oil temperature probe. The maintenance manual for the accident engine provided a torque range for the oil temperature port plug (with crush washer), as 190 in/lbs to 210 in/lbs. The version of the manual in effect at the time of the accident did not specify the orientation of crush washers.

Maintenance records revealed that the airplane's most recent annual inspection occurred on September 16, 2016. At that time, the airplane had accrued a total of 4,488 flight hours, and the engine had accrued a total of 832 hours since overhaul.

Pilot Information

Certificate: Private
Age: 56, 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 With Waivers/Limitations
Last FAA Medical Exam: 04/18/2016
Occupational Pilot: No
Last Flight Review or Equivalent: 07/19/2016
Flight Time:   1014 hours (Total, all aircraft), 708 hours (Total, this make and model), 964 hours (Pilot In Command, all aircraft), 23 hours (Last 90 days, all aircraft), 1 hours (Last 30 days, all aircraft), 1 hours (Last 24 hours, all aircraft) 



Aircraft and Owner/Operator Information

Aircraft Make: RYAN
Registration: N5327K
Model/Series: NAVION B
Aircraft Category: Airplane
Year of Manufacture: 1950
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: NAV-4-2227-B
Landing Gear Type: Retractable - Tricycle
Seats: 4
Date/Type of Last Inspection: 09/16/2016, Annual
Certified Max Gross Wt.: 2850 lbs
Time Since Last Inspection: 1 Hour
Engines: 1 Reciprocating
Airframe Total Time: 4488 Hours as of last inspection
Engine Manufacturer: Continental
ELT: C91A installed, not activated
Engine Model/Series: IO-550B
Registered Owner: On file
Rated Power: 300 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: KLYH, 938 ft msl
Distance from Accident Site: 16 Nautical Miles
Observation Time: 1754 EDT
Direction from Accident Site: 15°
Lowest Cloud Condition:
Visibility:  10 Miles
Lowest Ceiling: Broken / 7000 ft agl
Visibility (RVR):
Wind Speed/Gusts: 6 knots /
Turbulence Type Forecast/Actual: None / None
Wind Direction: 160°
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 29.89 inches Hg
Temperature/Dew Point: 24°C / 19°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: CULPEPER, VA (CJR)
Type of Flight Plan Filed: None
Destination: LONG ISLAND, NC (NC26)
Type of Clearance: None
Departure Time: 1700 EDT
Type of Airspace: Class G

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:  37.055278, -79.295000 (est)

Canadian Home Rotors Safari, operated under the provisions of 14 Code of Federal Regulations Part 91 as a personal local flight, N330JT: Accident occurred September 27, 2016 in Andover, Merrimack County, New Hampshire

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

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

Aviation Accident Factual 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/N330JT


Location: Andover, NH
Accident Number: ERA16LA330
Date & Time: 09/27/2016, 1554 EDT
Registration: N330JT
Aircraft: TATKOVSKY JAMES G SAFARI
Aircraft Damage: Destroyed
Defining Event: Abrupt maneuver
Injuries: 1 Serious
Flight Conducted Under: Part 91: General Aviation - Personal 

On September 27, 2016, about 1554 eastern daylight time, an experimental amateur-built Safari helicopter, N330JT, collided with trees and terrain during takeoff near Andover, New Hampshire. The pilot sustained serious injuries, and the helicopter was destroyed by a postcrash fire. The helicopter was being operated under the provisions of 14 Code of Federal Regulations Part 91 as a personal, local flight. Visual meteorological conditions prevailed at the time, and no flight plan was filed for the flight which was originating at the time of the accident.

The pilot, who did not hold a rotorcraft-helicopter category and class rating, stated that he pushed the helicopter out of the barn and onto a concrete pad and then added 10 gallons of 100 low lead fuel which filled both fuel tanks. He then performed a preflight inspection and found no discrepancies. After starting the engine, under calm wind, he flew to a pasture 20 to 25 ft away and landed, then practiced hovering, rearward flight, and turns. He then positioned the helicopter to a different portion of the field, which allowed for takeoff to the northwest towards trees. He lifted to a 5 ft hover (reported to be higher than usual because of rising terrain ahead), and added full power noting 27 inches of manifold pressure. Noting that the engine and main rotor tachometers were in the green arcs, he initiated takeoff and accelerated to between 25 and 30 mph. When the helicopter was above the height of a treeline ahead, the helicopter began, "a more vertical ascent than I could counteract with cyclic", with a corresponding decrease in airspeed. He adjusted the collective to maintain altitude and applied forward cyclic control input to increase airspeed. As the flight continued over the trees, the helicopter did not respond to forward cyclic control input. When near the far end of the trees, the "helicopter came to a complete stop" though the sound from the main rotor blades seemed to have increased. The helicopter yawed to the right and the nose dropped, then the tail boom "went down and swung left taking the helicopter into the trees." He exited the helicopter and was taken to a hospital for treatment of his injuries.

Examination of the accident site revealed the helicopter came to rest in a wooded area resting against the base of a small tree. The helicopter was resting on its left side in a nose-low attitude, and was extensively damaged by a postcrash fire, which destroyed the cockpit, and also involved the engine compartment/main rotor area. The tail boom with tail rotor drive shaft was displaced down relative to normal orientation of the helicopter. All components necessary to sustain flight remained attached or were in close proximity. According to a Federal Aviation Administration (FAA) airworthiness inspector who examined the helicopter, although it was extensively heat damaged, there was no evidence of preimpact failure or malfunction. The inspector did note that although the pilot had a repairman certificate, there was no permanent maintenance records or evidence of a condition inspection being performed since the helicopter was built in 2004. An FAA operations inspector reported that the pilot did not have a medical certificate, and was "…teaching himself to fly."

Although the pilot did not have a current medical certificate, he indicated there was nothing physically wrong with him that caused the accident. He reported having 154 hours total time in the accident make and model helicopter, of which 144 hours were as pilot-in-command. In the last 90 days he reported accruing 2 hours in the accident helicopter.

According to a representative of the helicopter manufacturer, unexpected movement of the collective could occur if either the collective spring or cable were to fail. As a result, they introduced installation of a redundant system consisting of a second spring and cable.

The pilot reported no failure or malfunction of the cyclic or collective flight controls from the cockpit to the main rotor. The helicopter was equipped with redundant collective springs and cables, neither of which were failed. The pilot did report that both springs exhibited evidence of slight elongation when compared with springs installed on an exemplar helicopter. 

Pilot Information

Certificate: Airline Transport
Age: 70, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Right
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: None None
Last FAA Medical Exam: 11/30/2009
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time: 154 hours (Total, this make and model)

Aircraft and Owner/Operator Information

Aircraft Make: TATKOVSKY JAMES G
Registration: N330JT
Model/Series: SAFARI 400
Aircraft Category: Helicopter
Year of Manufacture: 2004
Amateur Built: Yes
Airworthiness Certificate: Experimental
Serial Number: 0474N
Landing Gear Type: Skid
Seats: 2
Date/Type of Last Inspection: 05/07/2015, Condition
Certified Max Gross Wt.: 1450 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 154 Hours at time of accident
Engine Manufacturer: LYCOMING
ELT: Not installed
Engine Model/Series: O-320-B2A
Registered Owner: On file
Rated Power: 150 hp
Operator: On file
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: LEB, 603 ft msl
Distance from Accident Site: 26 Nautical Miles
Observation Time: 1553 EDT
Direction from Accident Site: 299°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: Calm /
Turbulence Type Forecast/Actual: /
Wind Direction:
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 29.88 inches Hg
Temperature/Dew Point: 22°C / 9°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Andover, NH
Type of Flight Plan Filed: None
Destination: Andover, NH
Type of Clearance: None
Departure Time: 1554 EDT
Type of Airspace:

Wreckage and Impact Information

Crew Injuries: 1 Serious
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: Unknown
Total Injuries: 1 Serious
Latitude, Longitude: 43.420833, -71.780556

Cessna P210N Pressurized Centurion, instructional flight conducted under the provisions of 14 Code of Federal Regulations Part 91, N224MH: Accident occurred September 16, 2016 at Lancaster Airport (KLNS), Lancaster County, Pennsylvania

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

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Harrisburg, Pennsylvania

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

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

http://registry.faa.gov/N224MH

Location: Lancaster, PA
Accident Number: ERA16LA318
Date & Time: 09/16/2016, 1105 EDT
Registration: N224MH
Aircraft: CESSNA P210
Aircraft Damage: Substantial
Defining Event: Landing gear collapse
Injuries: 2 None
Flight Conducted Under: Part 91: General Aviation - Instructional 

On September 16, 2016, at 1105 eastern daylight time, a Cessna P210, N224MH, operated by Ridge View Air, was substantially damaged following collapse of the main landing gear during landing at Lancaster Airport (LNS), Lancaster, Pennsylvania. The flight instructor and pilot receiving instruction were not injured. Visual meteorological conditions prevailed, and no flight plan was filed for the instructional flight, which was conducted under the provisions of 14 Code of Federal Regulations Part 91. The flight departed Chester County G O Carlson Airport (MQS), Coatesville, Pennsylvania, about 1045.

According to the flight instructor, the purpose of the flight was to conduct a training session for the pilot under instruction, who was pursuing high-performance and complex airplane endorsements. The first flight leg originated from LNS, and flew to MQS, where six uneventful full-stop landings were performed which included exercising the landing gear. The second and final leg of the flight was the return to LNS. Upon arrival, the pilot receiving instruction lowered the landing gear as the airplane entered a downwind traffic pattern leg for runway 08. Subsequently, both pilots twice confirmed the landing gear was in the down and locked position. During landing, the airplane initially touched down and then momentarily lifted off, and as it did so, the landing gear warning horn sounded. The flight instructor then took the controls and set the airplane down on the right main landing gear. As the airplane decelerated, the nose wheel touched down and a right yaw developed, the left wing settled onto the runway, and the airplane slid to a stop.

Examination of the accident scene by a Federal Aviation Administration (FAA) inspector revealed that the airplane came to rest upright on the right side of the runway oriented on heading of about 230 degrees magnetic. The airplane was resting on the left wingtip, fuselage, and nose wheel. Both main landing gear were collapsed and near their respective "up" positions, while the nose gear was in the down position and canted toward the right. A set of two tire marks about 350 feet long was found on the runway extending west from the airplane toward the approach end of the runway. A third tire mark extended about 150 feet west from the location of the nose wheel. The left horizontal stabilizer, left elevator, and left aileron were substantially damaged.

The airplane was examined again by FAA inspectors following its recovery to a hangar. The examination revealed that the right main landing gear lock mechanism was engaged, while the left main landing gear lock mechanism was disengaged. The airplane was then jacked and balanced such that all three landing gear were off the ground. The right main landing gear was manually unlocked, and hydraulic and electrical power applied to the airplane. As power was applied the gear unsafe horn sounded. The landing gear lever was moved to the extend position, and both main landing gear moved to the down and locked position. The main landing rear locks were manually released, and the procedure repeated two additional times, with the same results. The landing gear was not retracted during the test, due to the damage to the nose wheel assembly. The landing gear indicating system, unsafe warning horn, operating lever and main landing gear lock system all functioned properly. The hydraulic reservoir level was about 1/16 inch above the "add" line. The examination and tests did not reveal any preimpact mechanical malfunctions.

Review of maintenance records revealed that the airplane's most recent annual inspection occurred on December 4, 2015, at which time the airplane had accrued a total of 3,772 hours.

The recorded wind at LNS, at 1109, was from 160° at 5 knots.

Flight Instructor Information

Certificate: Airline Transport; Flight Instructor
Age: 28, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s):
Restraint Used: 3-point
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): Airplane Single-engine; Instrument Airplane
Toxicology Performed: No
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 08/02/2016
Occupational Pilot: Yes
Last Flight Review or Equivalent: 11/02/2015
Flight Time:  4790 hours (Total, all aircraft), 35 hours (Total, this make and model), 4760 hours (Pilot In Command, all aircraft), 150 hours (Last 90 days, all aircraft), 46 hours (Last 30 days, all aircraft), 3 hours (Last 24 hours, all aircraft)

Student Pilot Information

Certificate: Private
Age: 28, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): None
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 3 Unknown
Last FAA Medical Exam: 02/01/2015
Occupational Pilot: No
Last Flight Review or Equivalent: 11/23/2015
Flight Time:  140 hours (Total, all aircraft), 12 hours (Total, this make and model), 110 hours (Pilot In Command, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: CESSNA
Registration: N224MH
Model/Series: P210 N
Aircraft Category: Airplane
Year of Manufacture: 1978
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: P21000089
Landing Gear Type: Retractable - Tricycle
Seats: 6
Date/Type of Last Inspection: 12/04/2015, Annual
Certified Max Gross Wt.: 4000 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 3772 Hours as of last inspection
Engine Manufacturer: CONT MOTOR
ELT: Installed, not activated
Engine Model/Series: TSIO-520P5B
Registered Owner: RIDGE VIEW AIR INC
Rated Power: 285 hp
Operator: RIDGE VIEW AIR INC
Operating Certificate(s) Held: None 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: LNS, 403 ft msl
Distance from Accident Site: 0 Nautical Miles
Observation Time: 1109 EDT
Direction from Accident Site: 171°
Lowest Cloud Condition:
Visibility:  10 Miles
Lowest Ceiling: Overcast / 5500 ft agl
Visibility (RVR):
Wind Speed/Gusts: 5 knots /
Turbulence Type Forecast/Actual: None / None
Wind Direction: 160°
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 30.32 inches Hg
Temperature/Dew Point: 21°C / 13°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: COATESVILLE, PA (MQS)
Type of Flight Plan Filed: None
Destination: Lancaster, PA (LNS)
Type of Clearance: None
Departure Time: 1030 EDT
Type of Airspace: Class D 

Airport Information

Airport: LANCASTER (LNS)
Runway Surface Type: Asphalt
Airport Elevation: 402 ft
Runway Surface Condition: Dry
Runway Used: 08
IFR Approach: None
Runway Length/Width: 6933 ft / 150 ft
VFR Approach/Landing: Full Stop; Traffic Pattern 

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: 40.122222, -76.294444 (est)

Ground Collision: Bell OH-13H/M74A, N10009, accident occurred July 25, 2016 in Minonk, Woodford County, Illinois

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

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Springfield, Illinois

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/N10009

Location: Minonk, IL
Accident Number: CEN16LA284
Date & Time: 07/25/2016, 1050 CDT
Registration: N10009
Aircraft: TEXAS HELICOPTER CORP OH 13H/M74A
Aircraft Damage: Substantial
Defining Event: Ground collision
Injuries: 1 None
Flight Conducted Under: Part 137: Agricultural 

Analysis 

During reloading operations for an agricultural flight, the nurse truck was parked on the right shoulder of a road, facing west. The helicopter was parked on the elevated helipad on top of the nurse truck, facing north, with the engine running and rotor blades turning. The helicopter's tail boom and rotor disk extended about 8-10 ft over the road. As the loader was reloading the helicopter's product tanks, a westbound semi-trailer truck drove underneath the rotor disk and struck the helicopter's tail boom. The semi-trailer truck driver said he thought he had enough clearance to pass safely under the helicopter's tail rotor. The pilot said that if the nurse truck had parked closer to an adjoining field, the platform would have a tilt, making it difficult to land for servicing. It is likely that the semi-trailer truck driver failed to ensure that he had adequate clearance to pass under the helicopter and that the loader failed to park in a safer area for the reloading operations.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
Failure of the truck driver to ensure that he had adequate clearance to pass under the helicopter and the failure of the loader to park in a safer area for reloading operations.

Findings

Personnel issues
Planning/preparation - Ground crew (Cause)
Task performance - Other/unknown (Cause)


Factual Information

On July 25, 2016, about 1050 central daylight time, a Texas Helicopter OH-13H/M74A, N10009, was substantially damaged when it was struck by a passing semi-trailer truck during reloading operations near Minonk, Illinois. The pilot, loader, and truck driver were not injured. The helicopter was registered to and operated by Hendrickson Flying Service, Rochelle, Illinois, under the provisions of Title 14 Code of Federal Regulations Part 137 as an agricultural application flight. Visual meteorological conditions prevailed, and no flight plan for the local flight had been filed.

The agricultural application nurse truck was stationary and parked on the right shoulder of a paved rural county road, facing west, and was completely clear of the roadway surface. The helicopter was parked on the elevated helipad on top of the nurse truck with the helicopter's engine operating and the rotor blades turning. The nose of the helicopter faced north, and the helicopter's tail boom and rotor disk extended about 10 feet over the road.

A loader was standing on top of the elevated helipad and had just finished reloading the helicopter's product tanks. A westbound semi-trailer truck drove underneath the rotor disk and struck the helicopter's tail boom. The impact resulted in the complete separation of the aft half of the tail boom, and turned the helicopter 30° from its position on the helipad. The helicopter remained upright and remained on the top of the helipad. The loader also remained standing on top of the helipad. The right exhaust stack and top right edge of the truck trailer was crushed. The right side of the cab and the cargo cover and frame to the trailer were also damaged.

The truck driver told a Federal Aviation Administration (FAA) inspector that he thought he had enough clearance to pass safely under the helicopter's tail rotor. He maintained that the accident was not his fault. The pilot was asked why the truck was positioned so that the helicopter's tail boom was extended 10 feet over the highway. He replied that if he had parked closer to an adjoining field, the platform would have a tilt, making it difficult to land for servicing.

After examining the accident site, the inspector noted that were other flat areas in the vicinity but considered too far from the field being sprayed. 

Aircraft and Owner/Operator Information

Aircraft Make: TEXAS HELICOPTER CORP
Registration: N10009
Model/Series: OH 13H/M74A
Aircraft Category: Helicopter
Year of Manufacture: 1979
Amateur Built: No
Airworthiness Certificate: Restricted
Serial Number: 79-032
Landing Gear Type: Ski;
Seats: 1
Date/Type of Last Inspection:
Certified Max Gross Wt.: 2450 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time:
Engine Manufacturer: LYCOMING
ELT: Installed, not activated
Engine Model/Series: VO-435 A1F
Registered Owner: HENDRICKSON FLYING SERVICE INC
Rated Power: 200 hp
Operator: HENDRICKSON FLYING SERVICE INC
Operating Certificate(s) Held: Agricultural Aircraft (137)
Operator Does Business As: HENDRICKSON FLYING SERVICE
Operator Designator Code: HNKG

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KPNT, 659 ft msl
Distance from Accident Site: 17 Nautical Miles
Observation Time: 1055 CDT
Direction from Accident Site: 71°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 4 knots /
Turbulence Type Forecast/Actual: /
Wind Direction: 330°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 30.02 inches Hg
Temperature/Dew Point: 26°C / 23°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Minook, IL (NONE)
Type of Flight Plan Filed: None
Destination: Minook, IL (NONE)
Type of Clearance: None
Departure Time:
Type of Airspace: Class G 

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:  40.832778, -88.968889 (est)

Loss of Control on Ground: Nelson Woody, N525AG, accident occurred July 18, 2016 at Hope Municipal Airport (M18), Hempstead County, Arkansas

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

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Little Rock, Arkansas

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/N525AG

Location: Hope, AR
Accident Number: CEN16LA271
Date & Time: 07/18/2016, 0930 CST
Registration: N525AG
Aircraft: GERALD NELSON NELSON WOODY
Aircraft Damage: Substantial
Defining Event: Loss of control on ground
Injuries: 1 Serious, 1 Minor
Flight Conducted Under: Part 91: General Aviation - Personal 

Analysis 

The private pilot was conducting touch-and-go landings in the homebuilt, tailwheel-equipped, experimental airplane. After a normal touchdown, the airplane veered to the left off the asphalt runway surface and ground looped as it departed the runway, which resulted in substantial damage to the fuselage and left wing. Postaccident examination revealed that the left main landing gear retaining mechanism was broken, but it was not clear if the damage occurred before or after the loss of control. The pilot, who was the builder of the airplane and had about 500 hours of flight time in the airplane, reported that he believed that the retaining mechanism could have broken upon landing and resulted in the ground loop. The winds were light and variable at the time of the accident. Because the damage to the landing gear retention mechanism could have occurred before or after the loss of control, the reason for the loss of control could not be determined.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The loss of control upon landing for reasons that could not be determined.

Findings

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


Factual Information

On July 18, 2016, about 0930 central standard time, a Nelson Woody homebuilt, tailwheel-equipped, experimental airplane, N525AG, registered to the pilot, sustained substantial damage after veering off the runway during landing rollout at the Hope Municipal Airport (M18), Hope, Arkansas. The private pilot sustained serious injuries and one passenger sustained minor injuries. The personal flight was being conducted under the provisions of Federal Code of Regulations Part 91. Visual meteorological conditions prevailed throughout the vicinity and a flight plan was not filed. The flight originated from M18 about 0900.

According to the pilot, he was conducting touch and go landings at M18 on runway 16. Upon a normal touchdown, the aircraft veered to the left off the runway surface. There were ground impressions of the left wingtip and propeller marks on the ground. Evidence showed that the airplane ground looped as it departed the runway. Both occupants exited the aircraft and the pilot was transported to a local hospital for his injuries.

Examination of the airplane by an FAA inspector after the accident revealed that the left wing was bent downward mid-span about 90-degrees, and the fuselage was buckled. The left main landing gear retaining mechanism was found broken. It was not clear if the damage was pre or post impact. The pilot, who was the builder of the airplane and had about 500 hours of flight time in the airplane, reported that he believed that the retaining mechanism could have broken upon landing resulting in the ground loop.

The nearest weather reporting station, located in Texarkana, Arkansas, about 30 miles from the accident site, reported clear skies and variable winds at 4 knots. Local personnel located at the airport reported that it was a nice day with light winds on the day of the accident. 

Pilot Information

Certificate: Private
Age: 84, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Front
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 3 None
Last FAA Medical Exam: 10/16/2007
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time:  (Estimated) 1500 hours (Total, all aircraft), 500 hours (Total, this make and model), 1 hours (Last 24 hours, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: GERALD NELSON
Registration: N525AG
Model/Series: NELSON WOODY NO SERIES
Aircraft Category: Airplane
Year of Manufacture:
Amateur Built: Yes
Airworthiness Certificate: Experimental
Serial Number: 2281
Landing Gear Type: Tailwheel
Seats: 2
Date/Type of Last Inspection:  Unknown
Certified Max Gross Wt.:
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time:
Engine Manufacturer: Lycoming
ELT: Not installed
Engine Model/Series: O-290
Registered Owner: On file
Rated Power: 120 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: TXK
Distance from Accident Site: 30 Nautical Miles
Observation Time: 1016 CDT
Direction from Accident Site: 275°
Lowest Cloud Condition: Few / 3700 ft agl
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 4 knots /
Turbulence Type Forecast/Actual: /
Wind Direction: Variable
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 30.2 inches Hg
Temperature/Dew Point: 33°C / 22°C
Precipitation and Obscuration:
Departure Point: Hope, AR (M18)
Type of Flight Plan Filed:
Destination: Hope, AR (M18)
Type of Clearance: None
Departure Time: CST
Type of Airspace:

Airport Information

Airport: Hope Municipal Airport (M18)
Runway Surface Type: Concrete
Airport Elevation: 359 ft
Runway Surface Condition: Dry
Runway Used: 16
IFR Approach: None
Runway Length/Width: 5501 ft / 100 ft
VFR Approach/Landing: Touch and Go

Wreckage and Impact Information

Crew Injuries: 1 Serious
Aircraft Damage: Substantial
Passenger Injuries: 1 Minor
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Serious, 1 Minor
Latitude, Longitude: 33.723889, -93.655278

Friday, April 26, 2019

Czech SportCruiser, registered to and operated by Santa Monica Flyers Inc under the provisions of Title 14 Code of Federal Regulations Part 91 as an instructional flight, N1111X: Accident occurred May 22, 2016 at Santa Monica Municipal Airport (KSMO), Los Angeles County, California

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

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Los Angeles, California
Air Accidents Investigation Institute; FN
Rotech Flight Safety Inc; Vernon, British Columbia, Canada

Aviation Accident Factual 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/N1111X



Location: Santa Monica, CA
Accident Number: WPR16FA115
Date & Time: 05/22/2016, 1332 PDT
Registration: N1111X 
Aircraft: CZECH AIRCRAFT WORKS SPOL SRO SPORTCRUISER
Aircraft Damage: Substantial
Defining Event: Loss of engine power (partial)
Injuries: 1 None
Flight Conducted Under: Part 91: General Aviation - Instructional 

On May 22, 2016, at 1332 Pacific daylight time, a Czech Aircraft Works SPOL SRO, SportCruiser, N1111X, departed the runway after a loss of engine power during the initial climb from Santa Monica Municipal Airport (SMO), Santa Monica, California. The student pilot was not injured, and the airplane sustained substantial damage. The light-sport airplane was registered to and operated by Santa Monica Flyers, Inc., under the provisions of Title 14 Code of Federal Regulations Part 91 as an instructional flight. Visual meteorological conditions prevailed, and no flight plan had been filed. The local flight departed SMO at 1330.

The student pilot had just completed two uneventful takeoffs and landings while remaining within the traffic pattern. As he approached the hold short line for runway 21 in preparation for his third takeoff, an airplane in the traffic pattern declared an emergency, and tower controllers temporarily suspended all takeoffs. The pilot remained in the airplane with the engine still running at idle. He stated that while waiting, the airplane was on a heading of about 350°, and he monitored the engine's cylinder head temperatures and intermittently increased engine speed in an attempt to keep the engine cool.

After holding short for 20 minutes the pilot was given a takeoff clearance. The takeoff roll and initial climb were uneventful, however, once the airplane reached an altitude of about 500 ft above ground level (agl), the engine began to lose power, and the airplane began descending. The pilot stated that he did not have sufficient altitude to perform trouble shooting steps, and immediately initiated a 180o right turn in an effort to land back on runway 3. The airplane became realigned with the runway centerline about midfield, and after touchdown the pilot applied full brake pressure, but was unable to slow the airplane down sufficiently. The airplane passed through the northeast run-up area and taxiway, and departed the elevated section of the runway, dropping down onto the airport perimeter road 10 ft below.

Both the nose and main landing gear struck the curb, and the airplane came to rest on a grassy knoll within the airport perimeter, about 180 ft beyond the threshold of runway 21. The airplane sustained substantial damage to the firewall and lower fuselage structure during the accident sequence, and both wings, along with their integral fuel tanks, were intact and undamaged.

Student Pilot Information

Certificate: Student
Age: 50, Male
Airplane Rating(s): None
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 4-point
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Sport Pilot None
Last FAA Medical Exam:
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time:  46 hours (Total, all aircraft), 46 hours (Total, this make and model), 17.6 hours (Pilot In Command, all aircraft), 9 hours (Last 90 days, all aircraft), 2.5 hours (Last 30 days, all aircraft), 0.9 hours (Last 24 hours, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: CZECH AIRCRAFT WORKS SPOL SRO
Registration: N1111X
Model/Series: SPORTCRUISER
Aircraft Category: Airplane
Year of Manufacture: 2008
Amateur Built: No
Airworthiness Certificate: Special Light-Sport
Serial Number: 08SC176
Landing Gear Type: Tricycle
Seats: 2
Date/Type of Last Inspection: 04/08/2016, 100 Hour
Certified Max Gross Wt.: 1320 lbs
Time Since Last Inspection: 61 Hours
Engines: 1 Reciprocating
Airframe Total Time: 3423.7 Hours as of last inspection
Engine Manufacturer: Rotax
ELT:  C91A installed, activated, did not aid in locating accident
Engine Model/Series: 912ULS
Registered Owner: SANTA MONICA FLYERS INC
Rated Power: 100 hp
Operator: SANTA MONICA FLYERS INC
Operating Certificate(s) Held: None

The airplane was manufactured in 2008, and equipped with a 4-cylinder, liquid-/air-cooled, Rotax 912-ULS engine. 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KSMO, 174 ft msl
Distance from Accident Site: 0 Nautical Miles
Observation Time: 1351 PDT
Direction from Accident Site: 223°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 10 knots / 19 knots
Turbulence Type Forecast/Actual: /
Wind Direction: 250°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 30.02 inches Hg
Temperature/Dew Point: 18°C / 11°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: SANTA MONICA, CA (SMO)
Type of Flight Plan Filed: None
Destination: SANTA MONICA, CA (SMO)
Type of Clearance: VFR
Departure Time: 1330 PDT
Type of Airspace: Class D

Airport Information

Airport: SANTA MONICA MUNI (SMO)
Runway Surface Type:Asphalt 
Airport Elevation: 177 ft
Runway Surface Condition: Dry
Runway Used: 03
IFR Approach: None
Runway Length/Width: 4973 ft / 150 ft
VFR Approach/Landing: Forced Landing

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: 34.021111, -118.445278 

Post-accident examination at the accident site by the NTSB investigator-in-charge (IIC) revealed that the left- and right-wing fuel tanks both contained fuel, along with both carburetor bowls. A follow up examination was performed; there was no evidence of oil or coolant loss, and no anomalies with the airframe or engine were found which would have precluded normal operation.

The engine was then removed and transported to the facilities of Rotech Flight Safety (Rotax Aircraft Engines) for further examination and an engine test run. No anomalies were noted, and the engine performed nominally at all speeds in an engine test cell.

A complete examination report is contained in the public docket.

Engine Monitor

The airplane was equipped with a Dynon EMS-D120 engine monitoring system, mounted on the right side of the instrument panel, which was configured to record engine parameters including oil pressure and temperature, fuel pressure and flow, manifold pressure, engine speed, and the cylinder and exhaust gas temperatures (CHT, EGT) for cylinders one and two. The unit also recorded the airplane's GPS position and ground speed.

Examination of the data revealed that for both prior takeoffs and landings, the fuel flow remained at about 1 gallon per hour (gph) during the ground idle phase, and climbed to about 6.5 gph during the takeoff and initial climb. Oil temperatures remained at about 175° F throughout, and cylinder head temperatures averaged about 175° F on the ground, and 230° F during takeoff. Engine speed during takeoff was about 5,100 rpm, and manifold pressure dropped from 29.1 to 27.8 inches of mercury as the climb progressed.

For the first ten minutes while the airplane was holding short and waiting for the takeoff clearance of the accident flight, the CHT's began to climb, with cylinder 2 reaching an average of about 330° F. During that period, the oil temperature climbed to 222° F while the oil pressure began to drop from about 46 to 30 lbs per square inch (psi). Fuel flow and pressure remained constant at about 1 gph and 5 psi respectively.

During the next 10 minutes, the oil temperature continued to rise with an accompanying drop in oil pressure, while the fuel flow began to oscillate, varying between 0 and 3 gph. About two minutes before takeoff, the oil temperature reached its highest average level of 270° F, with intermittent readings reaching as high as 337° F, while the oil pressure had dropped to 22 psi. The takeoff then began, but the fuel flow, rather than reaching 6.5 gph as before, began to oscillate between 5.4 and 9.1 gph. The engine speed reached 4,800 rpm for about 30 seconds, and then dropped to about 4,300 rpm; the manifold pressure remained steady at 30.03 inches of mercury throughout the takeoff and initial climb, until the data ended.

During the ten minutes while the airplane was holding short just before takeoff, two distinct increases in engine speed of about 400 rpm were observed, lasting 30 and 60 seconds respectively. These changes appeared consistent with the pilot's attempt to keep the engine cool. The speed changes did not make any appreciable difference to the average engine temperatures. 

Additional Information

The engines temperature operating limitations, documented in both the flight manual and on the EMS-D120 gauges (through green, yellow, and red display bands), indicated the following:

Normal operating range for oil temperature was between 194 and 230 °F, with a caution range of 230 to 266 °F and a maximum (red-line) limit of 266 °F. The normal cylinder head temperature operating range was between 167 and 230 °F, the caution range was 230 to 275 °F, and the maximum limit was 275 °F.

The EMS-D120 was capable of displaying discrete alerts in the event of engine temperature exceedances, however the alert feature had not been enabled.

The SportCruiser pilot operating handbook (POH) warned that takeoff is prohibited if engine instrument values are above operational limits.

Fuel Flow Sensors

The airplane was equipped with a FloScan 200 series fuel flow transducer. The unit's design incorporated an internal rotor mounted within a chamber. As fuel passed through the chamber, the rotor spun, interrupting an opto-electronic pickup, which created a pulsed electrical signal - the period of which was proportional to the fuel flow rate.

According to technical representatives from FloScan, the introduction of air into the fuel supply lines can cause the unit to read higher than normal fuel flow rates.

According to technical representatives from Electronics International Inc. (EI) (who manufacture the FT-60 fuel flow transducer, installed on later models of the SportCruiser), when air inadvertently enters a rotor style flow transducer through the fuel lines, the rotor is free to spin at the velocity of the air that passes over it. This velocity is higher for air than it is for fuel, and as such "vapor lock" is often represented as spikes in fuel flow. Additionally, with air in the system, pulses of air from the fuel pump can cause the rotor to spin back and forth in both directions. Under these conditions, the pickup still measures flow irrespective of direction, resulting in "jumping" fuel flow readings.

Fuel and Fuel Testing

Although the engine was capable of operating on 100 low-lead aviation gasoline, Rotax Engines recommended the use of automotive gasoline, because the lead in aviation fuel can cause stress on the valve seats, as well as create excessive lead deposits within the combustion chamber. The SportCruiser POH made similar recommendations, with the caveat that aviation gasoline should only be used, "in case of problems with vapor lock or when other types of gasoline are unavailable".

Both Rotax Engines and Czech Aircraft Works recommended using automotive gasoline which meets the American Society for Testing and Materials (ASTM) standard D4814. The Rotax operating manual, and placards mounted throughout the airplane, indicated that fuel with a minimum research octane number (RON) of 95 and anti-knocking index (AKI) of 91 can be used. Rotax further stated in the engine operating manual, "Use only fuel suitable for the respective climatic zone", and "Risk of vapor formation if using winter fuel for summer operation".

According to representatives from Santa Monica Flyers, their Rotax-equipped fleet was fueled with premium-grade automotive fuel purchased from a local automotive gasoline station, and then transported to the airport in a fuel truck. The last fill-up occurred the morning of the accident, and the accident airplane used fuel from that delivery.

Fuel from the left wing fuel tank (the tank selected for the flight) was recovered from the airplane at the accident site, and analyzed at a petroleum testing laboratory. The results revealed that the fuel was the appropriate blend for the region and time of year, and had a RON value of 95.8.

Fuel System

An amendment to the Rotax 912-ULS installation manual was added on August 1, 2012. The amendment required the installation of a fuel return line, designed to prevent engine malfunctions caused by the formation of vapor in the fuel system. The amendment stated that compliance was mandatory. It further stated:

"If the fuel distributor piece with regulator from Rotax is not available, the fuel pressure must be regulated by a restriction in the fuel return line, which ensures that the fuel pressure is under all operation condition within the operating limits specified by Rotax."

Examination of the airplane's fuel system revealed that the fuel return line had not been installed. According to representatives from Czech Aircraft Works, the installation of a fuel return line was made standard on all SportCruiser airplanes manufactured after September 2010.

A series of safety alerts were issued by Czech Aircraft Works during the two-year period following the accident, in response to limiting the possibility of vapor lock, specifically:

Safety Alert SA-SC-006, issued on October 16, 2017 mandated the installation of a fuel return line in accordance with the updated recommendations in Chapter 73-00-00, of the Rotax installation manual. The alert was applicable to all SportCruiser airplanes manufactured before May 14, 2009 (The accident airplane was manufactured in 2008).

Safety Alert SA-SC-011, issued on August 31, 2018, provided a set of updates to the POH regarding engine operation. One of the updates required the following addition to all sections of the POH that mentioned fuel:

WARNING

"Use only fuel formulated for the specific climate zone.
Pay special attention to the current outside air temperature.
Do not use winter MOGAS blends in warmer than normal temperatures.
RISK OF VAPOR FORMATION IF WINTER FUEL IS USED FOR SUMMER OPERATION."

The Pilot's Handbook of Aeronautical Knowledge (FAA-H-8083-25A) defines vapor lock as, "A problem that mostly affects gasoline-fueled internal combustion engines. It occurs when liquid fuel changes state from liquid to gas while still in the fuel delivery system. This disrupts the operation of the fuel pump, causing loss of feed pressure to the carburetor or fuel injection system, resulting in transient loss of power or complete stalling. Restarting the engine from this state may be difficult. The fuel can vaporize due to being heated by the engine, by the local climate, or due to a lower boiling point at high altitude."