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."

AgustaWestland AW139, registered to and operated by Chevron USA Inc under the provisions of Title 14 Code of Federal Regulations Part 91 as business flight, N639NA: Accident occurred April 07, 2016 in Galliano, Louisiana

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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Jackson, Mississippi
Italian Safety Investigation Authority, ANSV; FN
Leonardo Helicopters; FN
Leonardo Helicopters

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/N639NA

Location: Galliano, LA
Accident Number: CEN16LA401
Date & Time: 04/07/2016, CDT
Registration: N639NA
Aircraft: AGUSTAWESTLAND PHILADELPHIA AW139
Aircraft Damage: Substantial
Defining Event: Part(s) separation from AC
Injuries: 9 None
Flight Conducted Under: Part 91: General Aviation - Other Work Use 

HISTORY OF FLIGHT

On April 7, 2016, at an unknown time, an AgustaWestland AW139 helicopter, N639NA, sustained damage to a main rotor blade during a flight over the Gulf of Mexico. The pilot, co-pilot, and 7 passengers were not injured, and the helicopter sustained substantial damage. The helicopter was registered to and operated by Chevron USA Inc., under the provisions of Title 14 Code of Federal Regulations Part 91 as business flight. Visual meteorological conditions prevailed for the flight and a company visual flight rules (VFR) flight plan had been filed. The flight originated at 0600 from South Lafourche Leonard Miller Jr. Airport, (GOA), Galliano, Louisiana, with an en route stop at an oil rig in the Gulf of Mexico and terminated at GOA about 1135.

On May 9, 2018, the Chevron aviation department reported the accident to the NTSB and stated that during the flight the crew felt a slight vibration of the tail rotor. After landing at GAO during a post flight inspection, one of the tail rotor blade (TRB) erosion shield extensions (figure 1) commonly known as a lightning strip (LS) was missing and only its side tabs remained attached to the blade. Additionally, a main rotor blade (MRB) tip was damaged.


Figure 1 – TRB erosion shield extension diagram with notations (Courtesy of Leonardo)

PERSONNEL INFORMATION

AIRCRAFT INFORMATION

The separated LS was identified as part number (p/n) 3G6410L00152 that was manufactured in electroplated nickel.

Chevron reported that as a normal maintenance practice, an LS would be installed as a brand new part or as an "on-condition" item that had been installed at the discretion of the company maintenance personnel after the component was inspected and determined to be in airworthy condition.

Chevron reported that the associated tail rotor blade (TRB) was received new from Leonardo on May 22, 2015, without an LS installed. An LS was subsequently installed by Chevron with no serial number tracking requirement.

On January 30, 2016, the white TRB was removed and replaced due to wear on the main erosion shield from contact with the LS. The same LS was reinstalled on the replacement white TRB.

From February 26, 2016, to April 6, 2016 the helicopter accumulated 129.1 flight hours with the new TRB installed. During that time, 34 daily serviceability checklist inspections were completed and no discrepancies applicable to the LS on the white TRB (or any other TRB) were noted.

METEOROLOGICAL INFORMATION

WRECKAGE AND IMPACT INFORMATION

A Chevron post flight inspection of the helicopter revealed that the LS on the white TRB was fractured and most of the component was missing. Only the side tabs, where the tail rotor damper bracket bushings pass through, remained attached (figure 2).


Figure 2 – Damaged Tail Rotor Erosion Shield Extension (Courtesy of Chevron)

The inspection also found damage to one of the main rotor blades; the blue MRB tip sustained damage mostly on the under side of the blade (figure 3). No additional damage was observed on the remainder of the helicopter.


Figure 3 – Damaged Main Rotor Blade (Courtesy of Chevron)

TESTS AND RESEARCH

Failure Analysis

Leonardo, the current AW139 helicopter manufacturer, performed a failure analysis on the remaining portion of the LS, using a scanning electron microscope (SEM), which revealed the presence of microcavity spots or porosity on the surface of the fractured section (figure 4). In the figure, the area circled in yellow is the microcavity, the red dashes indicate the crack initiation, and the blue arrows indicate the direction of the fatigue crack propagation.


Figure 4 – SEM image of the fatigue propagation from a micro-cavity, yellow circle (Courtesy of Leonardo)


Figure 5 shows a wide view of the fracture surface with the crack origination circled in red.

Figure 5 – SEM image, wide view of fracture surface (Courtesy of Leonardo)

Static Testing

Finite element modeling (FEM) of an exemplar LS was completed to determine the expected inflight stress values, to include the influence of the centrifugal force and the bending moment due to the deformation of the TRB under beam bending loads. The simulation showed that the maximum stress values in the crack initiation area were considerably lower than the fatigue limit specified for the electroplated nickel material. Of note, the FEM model considered the geometric and fitting stress concentrations without the presence of a material flaw (such as a microcavity).

Flight Testing

A flight test was performed to evaluate the load conditions of the LS during flight. Strain measurement instrumentation was installed on a Leonardo helicopter to monitor and record the load conditions. Test results did not reveal any particular load condition that could lead to similar LS failures experienced during the accident flight.

ADDITIONAL INFORMATION

Related Events

Leonardo identified 6 additional events involving the same LS part number and the three scenarios are listed below. Of note, all three scenarios resulted in an uneventful landing.

LS crack identified during scheduled inspections (3 events)
LS fractured and separated in flight (2 events)
LS fractured and separated inflight, which resulted in damage to MRB tip (2 events, including the accident flight)

Corrective Actions

In response to the reports of similar LS failures, Leonardo changed the specification from electroplated nickel to a higher strength steel. As of July 31, 2017, for all newly built helicopters, the TRB installation drawing was updated to prescribe the installation of a steel LS, p/n 3G6410A03053, (figure 6). Additionally, Leonardo will issue an optional service bulletin to provide the steel LS upon customer request.


Figure 6 – Diagram of the updated steel LS (left) and electroplated nickel LS (right)

Pilot Information

Certificate: Airline Transport
Age: 52, Male
Airplane Rating(s): None
Seat Occupied: Right
Other Aircraft Rating(s): Helicopter
Restraint Used: 4-point
Instrument Rating(s): Helicopter
Second Pilot Present: Yes
Instructor Rating(s): Helicopter
Toxicology Performed: No
Medical Certification: Class 1 Without Waivers/Limitations
Last FAA Medical Exam: 02/19/2016
Occupational Pilot: Yes
Last Flight Review or Equivalent: 10/31/2015
Flight Time:  14500 hours (Total, all aircraft), 1250 hours (Total, this make and model), 12000 hours (Pilot In Command, all aircraft), 125 hours (Last 90 days, all aircraft), 35 hours (Last 30 days, all aircraft), 6 hours (Last 24 hours, all aircraft) 

Co-Pilot Information

Certificate: Airline Transport
Age: 35, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): Helicopter
Restraint Used: 4-point
Instrument Rating(s):
Second Pilot Present: Yes
Instructor Rating(s): Helicopter; Instrument Helicopter
Toxicology Performed: No
Medical Certification: Class 1 Without Waivers/Limitations
Last FAA Medical Exam: 03/20/2016
Occupational Pilot: Yes
Last Flight Review or Equivalent: 10/31/2015
Flight Time:  5792 hours (Total, all aircraft), 1813 hours (Total, this make and model), 2866 hours (Pilot In Command, all aircraft), 114 hours (Last 90 days, all aircraft), 32 hours (Last 30 days, all aircraft), 6 hours (Last 24 hours, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: AGUSTAWESTLAND PHILADELPHIA
Registration: N639NA
Model/Series: AW139
Aircraft Category: Helicopter
Year of Manufacture: 2013
Amateur Built: No
Airworthiness Certificate: Transport
Serial Number: 41326
Landing Gear Type: Emergency Float; Tricycle
Seats: 14
Date/Type of Last Inspection: 04/06/2016, Continuous Airworthiness
Certified Max Gross Wt.: 14991 lbs
Time Since Last Inspection:
Engines: 2 Turbo Shaft
Airframe Total Time: 2497.8 Hours at time of accident
Engine Manufacturer: P&W CANADA
ELT: C126 installed, not activated
Engine Model/Series: PT6C-67C
Registered Owner: CHEVRON USA INC
Rated Power: 1531 hp
Operator: CHEVRON USA INC
Operating Certificate(s) Held: On-demand Air Taxi (135)
Operator Does Business As:
Operator Designator Code: AC2A 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KXPY, 99 ft msl
Distance from Accident Site: 19 Nautical Miles
Observation Time: 0915 CDT
Direction from Accident Site: 170°
Lowest Cloud Condition:
Visibility:  10 Miles
Lowest Ceiling: 
Visibility (RVR):
Wind Speed/Gusts: 7 knots /
Turbulence Type Forecast/Actual:
Wind Direction: 340°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 30.03 inches Hg
Temperature/Dew Point: 22°C / 12°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: GALLIANO, LA (GAO)
Type of Flight Plan Filed: Company VFR
Destination: Galliano, LA (GAO)
Type of Clearance: None
Departure Time: 0600 CDT
Type of Airspace: Class E; Class G

Airport Information

Airport: SOUTH LAFOURCHE LEONARD MILLER (GAO)
Runway Surface Type: N/A
Airport Elevation: 0 ft
Runway Surface Condition: Unknown
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: None

Wreckage and Impact Information

Crew Injuries: 2 None
Aircraft Damage: Substantial
Passenger Injuries: 7 None
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 9 None
Latitude, Longitude: 29.438056, -90.262500 (est)

Cessna 175B Skylark, personal flight conducted under the provisions of Title 14 Code of Federal Regulations Part 91, N8115T: Accident occurred April 02, 2016 in Hurley, Jackson County, Mississippi

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

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Jackson, Mississippi 

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/N8115T 


Location: Hurley, MS
Accident Number: ERA16LA145
Date & Time: 04/02/2016, 1707 CDT
Registration: N8115T
Aircraft: CESSNA 175B
Aircraft Damage: Substantial
Defining Event: Loss of engine power (partial)
Injuries: 1 None
Flight Conducted Under: Part 91: General Aviation - Personal 

On April 2, 2016, about 1707 central daylight time, a privately owned and operated Cessna 175B, N8115T, was substantially damaged during a forced landing to a field near Hurley, Mississippi. The commercial pilot, the sole occupant was not injured. Visual meteorological conditions prevailed at the time and no flight plan was filed for the personal flight that was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. The flight originated about 7 minutes earlier from Mobile Regional Airport (MOB), Mobile, Alabama, and was destined for Slidell Airport (ASD), Slidell, Louisiana.

The pilot noted no discrepancies during his preflight inspection or engine-run up in advance of the first flight after completion of an annual inspection that was completed the day before. After takeoff, while in contact with air traffic control, the pilot climbed to between 1,200 and 1,500 feet mean sea level (msl) and after levelling off, he slowly leaned the fuel to air ratio. After moving the mixture control about 1/4 to 1/2 inch, the engine rpm "abruptly" decreased from 2,900 to 1,200. He promptly pushed the mixture control full-in, but that action did not restore engine power. He twice advanced the throttle fully forward, and the engine power briefly increased, before again falling back to idle. When the flight descended below 1,000 feet msl, he informed the controller of the situation and was provided with radar vectors to a nearby private airport.

With insufficient altitude available to glide to the airport and inadequate power to sustain flight, he maneuvered the airplane for a forced landing to a field. During the landing roll the nose landing contacted the upslope portion of a ditch, causing the nose landing gear to separate from the airplane. The airplane then slid about 100 feet, and came to rest upright in a nose-low/tail-high attitude. The pilot then exited the airplane, provided his mechanic the location coordinates, and rescue services were dispatched. The pilot was taken to a nearby hospital and while there, he and the mechanic who performed the last inspection discussed the possible causes of the loss of engine power. During that conversation, the pilot reported being advised by the mechanic that during an engine run, the engine had lost power quickly during manipulation of the mixture control. The pilot did not question the mechanic on that detail at that time.

Examination of the airplane by a Federal Aviation Administration inspector revealed the mixture control in the cockpit was in the full rich position but was idle cut-off position at the carburetor. The mixture control was pulled out but this action did not cause complete movement of the mixture control lever at the carburetor. The mixture control in the cockpit was pushed in, and the mixture lever at the carburetor only travelled half the distance of full travel. Further examination of the mixture control cable revealed a plastic sheath covered the cable between the mixture control lever at the carburetor and a baffle located aft of the engine. The sheath covered the cable in an area that was secured by a clamp attached near the mixture control lever at the carburetor.

Following recovery of the airplane, further examination of the mixture control cable revealed it and the plastic sheath covering it were loose within a clamp near the carburetor, and no rubber grommets within the clamp were noted. The mixture lever in the cockpit was moved from full lean to full rich, but the mixture control lever at the carburetor only moved a fraction of an inch and flexing of the mixture control cable was noted. In advance of an engine run, fuel that was drained from the wings was plumbed directly to the fuel line at the left wing root and the mixture control in the cockpit was place in the full rich position. The engine was started and the mixture control in the cockpit was moved toward the lean position, but the engine began to lose power. The mixture control in the cockpit was pushed to full rich but the engine lost power. In advance of a second test run, the plastic sheath and mixture control cable were placed inside the clamp near the carburetor, and the clamp was tightened. The mixture control in the cockpit was placed in the full rich position, and the engine was started. The mixture control in the cockpit was leaned and the sheath came out of the clamp and the engine again lost power. In advance of the final test run, the mixture lever at the carburetor was fixed in the full-rich position. The engine started uneventfully and was operated to 1,800 rpm where normal rpm drop during magneto checks were noted. Engine operation at a higher rpm was not performed due to safety concerns. No anomalies were noted with the engine during the engine run with the mixture control fixed in the full-rich position.

A review of the Illustrated Parts Catalog revealed no listing for plastic sheathing to cover the mixture control cable.

The 100-hour inspection checklist utilized by the mechanic specified an inspection of the engine controls and linkage for security, proper rigging, and binding. The mechanic indicated that during his inspection of the mixture control he noted it moved full travel but did not move as far as he was accustomed. He also indicated that he twice ran the engine during post maintenance checks and was able to lean and secure the engine using the mixture control with no issues.

Pilot Information

Certificate: Commercial
Age: 25, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): Helicopter
Restraint Used: Lap Only
Instrument Rating(s): Airplane; Helicopter
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 3 Without Waivers/Limitations
Last FAA Medical Exam: 01/30/2013
Occupational Pilot: No
Last Flight Review or Equivalent: 06/29/2015
Flight Time:  400 hours (Total, all aircraft), 45 hours (Total, this make and model), 3 hours (Last 24 hours, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: CESSNA
Registration: N8115T
Model/Series: 175B B
Aircraft Category: Airplane
Year of Manufacture: 1960
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 17556815
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection: 04/01/2016, Annual
Certified Max Gross Wt.: 2350 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 2989.6 Hours as of last inspection
Engine Manufacturer: Teledyne Continental
ELT: Installed, activated, aided in locating accident
Engine Model/Series:  GO-300-D
Registered Owner: Registration Pending
Rated Power: 175 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: MOB, 219 ft msl
Distance from Accident Site: 10 Nautical Miles
Observation Time: 1656 CDT
Direction from Accident Site: 85°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 15 knots / 20 knots
Turbulence Type Forecast/Actual: / None
Wind Direction: 340°
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 30 inches Hg
Temperature/Dew Point: 21°C / 2°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Mobile, AL (MOB)
Type of Flight Plan Filed: None
Destination: Slidell, LA (ASD)
Type of Clearance: None
Departure Time: 1700 CDT
Type of Airspace:

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: 30.675278, -88.430556

Robinson R44 II, operated under the provisions of 14 Code of Federal Regulations Part 91 as a local air tour flight, N7512N: Accident occurred November 26, 2015 at Destin Executive Airport (KDTS), Okaloosa 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; Vestavia Hills, 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/N7512N

Location: Destin, FL
Accident Number: ERA16LA054
Date & Time: 11/26/2015, 1145 CST
Registration: N7512N
Aircraft: ROBINSON HELICOPTER COMPANY R44 II
Aircraft Damage: Substantial
Defining Event: Sys/Comp malf/fail (non-power)
Injuries: 4 None
Flight Conducted Under: Part 91: General Aviation - Other Work Use - Sightseeing 

On November 26, 2015, about 1145 central standard time, a Robinson R44II, N7512N, was substantially damaged during a separation of the tail rotor drive shaft during a power check at the Destin Executive Airport, Destin, Florida. The commercial pilot and 3 passengers were not injured. The helicopter was being operated under the provisions of 14 Code of Federal Regulations Part 91, as a local air tour flight. Visual meteorological conditions prevailed in the area at the time of the accident, and no flight plan was filed for the local flight. The flight was originating at the time of the accident.

The pilot stated that he performed a preflight inspection of the helicopter and the passengers then boarded the helicopter. The engine was started and ground run-up checks of the engine were satisfactory. While doing a power check which involved applying up collective, he heard a loud pop. He responded by immediately lowering the collective and secured the helicopter.

Examination of the helicopter revealed the steel tail rotor drive shaft part number (P/N) C196-1 was circumferentially fractured at the weld of the forward flange; a portion of the intermediate flex plate P/N A947-2, remained bolted to the flange. The remaining portion of the flex plate remained bolted to the clutch shaft yoke, P/N C195. The tailcone attachment frame P/N C237-1, and the damper assembly mount angle was fractured. There was no report of any damage to any frame or interior of the tailcone aft of the damper. The helicopter time at the time of the accident was reported to be 1,770 hours. A section of the tail rotor drive shaft assembly containing the fracture, separated flange with attached portion of flex plate, and clutch shaft yoke with remaining portion of flex plate were retained for examination by the NTSB Materials Laboratory.

According to the NTSB Materials Laboratory factual report, the fracture between the tail rotor drive shaft and flange was consistent with torsional overstress. The report also indicated that a portion of flex plate attached to the flange also exhibited features consistent with overstress. Inspection of the bolted connection between the clutch shaft yoke and the portion of the flex plate revealed all of the hardware was in the correct sequence with the exception of the omission of a washer between the flex plate and the clutch shaft yoke. The washer omission was consistent on both of the connections between the clutch shaft yoke and the flex plate. The hardware stack-up for the connection between the flex plate and the portion of the drive shaft flange was correct.

Review of the maintenance records revealed an entry dated November 12, 2015, at helicopter total time of about 1,759 hours, indicating in part that the sprag clutch was removed and replaced.

Review of the maintenance manual revealed that with respect to the C-195 yoke removal and installation, a caution indicates, "There must be one AN960-416L or one AN960-416 washer between each arm of C195 yoke and A947-2 flex plate…." The maintenance manual also references Section 7.330, which pertains to intermediate flex plate installation and shimming. That section contains measurements to determine proper shimming required at the intermediate flex plate.

The mechanic who performed the clutch removal and installation stated that the measurements he took at the intermediate flex plate during and after his repairs were exactly the same. He also indicated that when they installed new hardware, he obtained the same dimensions.

According to the maintenance record entry returning the helicopter to service after the accident, there was no record that the governor was removed, replaced, or repaired.

According to a representative of the helicopter manufacturer, if misalignment of the clutch shaft, sheave, and intermediate flex coupling was not corrected during installation, there could be significant preload or tension in the entire length of driveshaft between the main rotor gearbox and tail rotor gearbox. The representative also indicated that the effect of a missing washer would have caused fatigue type failure of the tailrotor drive-line, and they had not previously seen a failure of the tail rotor driveshaft at the flange as had occurred in the accident helicopter. 

Pilot Information

Certificate: Flight Instructor; Commercial
Age: 27, Male
Airplane Rating(s): None
Seat Occupied: Left
Other Aircraft Rating(s): Helicopter
Restraint Used: 3-point
Instrument Rating(s): Helicopter
Second Pilot Present: No
Instructor Rating(s): Helicopter; Instrument Helicopter
Toxicology Performed: No
Medical Certification: Class 2 Without Waivers/Limitations
Last FAA Medical Exam: 02/25/2015
Occupational Pilot: Yes
Last Flight Review or Equivalent: 04/02/2015
Flight Time:  1021 hours (Total, all aircraft), 972 hours (Pilot In Command, all aircraft), 90 hours (Last 90 days, all aircraft), 24 hours (Last 30 days, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: ROBINSON HELICOPTER COMPANY
Registration: N7512N
Model/Series: R44 II
Aircraft Category: Helicopter
Year of Manufacture: 2003
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 10131
Landing Gear Type: Skid;
Seats: 4
Date/Type of Last Inspection: 11/12/2015, 100 Hour
Certified Max Gross Wt.: 2500 lbs
Time Since Last Inspection: 11 Hours
Engines: 1 Reciprocating
Airframe Total Time: 1758.8 Hours as of last inspection
Engine Manufacturer: LYCOMING
ELT: Not installed
Engine Model/Series: IO-540-AE1A5
Registered Owner: PROVAC LLC
Rated Power: 285 hp
Operator: Timberview Helicopters
Operating Certificate(s) Held: None 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: DTS, 22 ft msl
Distance from Accident Site:
Observation Time: 1153 CST
Direction from Accident Site:
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 6 knots /
Turbulence Type Forecast/Actual: / Unknown
Wind Direction: 50°
Turbulence Severity Forecast/Actual: / Unknown
Altimeter Setting: 30.42 inches Hg
Temperature/Dew Point: 23°C / 14°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Destin, FL (DTS)
Type of Flight Plan Filed: None
Destination: Destin, FL (DTS)
Type of Clearance: None
Departure Time: 1145 CST
Type of Airspace: 

Airport Information

Airport: Destin Executive (DTS)
Runway Surface Type: N/A
Airport Elevation: 22 ft
Runway Surface Condition:
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: None

Wreckage and Impact Information

Crew Injuries: 1 None
Aircraft Damage: Substantial
Passenger Injuries: 3 None
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 4 None
Latitude, Longitude:  30.400000, -86.471389 (est)

Loss of Engine Power (Total): SkyStar Kitfox Series 5, N533RC; accident occurred October 14, 2015 near Goheen Airport (W52), Battle Ground, Clark County, Washington

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

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Hillsboro, Oregon

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

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

https://registry.faa.gov/N533RC



Location: Battle Ground, WA
Accident Number: WPR16LA011
Date & Time: 10/14/2015, 1145 PDT
Registration: N533RC
Aircraft: CHRISTOPHER TOM KITFOX  5
Aircraft Damage: Substantial
Defining Event: Loss of engine power (total)
Injuries: 2 None
Flight Conducted Under: Part 91: General Aviation - Personal 

On October 14, 2015, about 1145 Pacific daylight time, an experimental amateur built Christopher Kitfox 5 airplane, N533RC, collided with a fence following a loss of engine power during the takeoff climb from a private grass strip near Battle Ground, Washington. The private pilot and passenger were not injured; the airplane sustained substantial damage. The airplane was registered to and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed at the time of the accident, and no flight plan was filed. The local flight was originating at the time of the accident.

According to the pilot, after take off from his grass airstrip, he made a left 45°  climbing turn when the engine began to run rough, then it regained full power. The airplane climbed to about 300 ft above ground when the engine ran rough again, then lost power. The pilot realized that he did not have sufficient altitude to make it to nearby Goheen Airport (W52), Battle Ground so he turned back toward the departure airstrip as he knew there were multiple open fields in the area. As he maneuvered around trees and fences for a forced landing, the airplane subsequently collided with a fence and nosed over, coming to rest inverted.

The pilot stated that he had drained fuel during the preflight check and reported no water present; however, he believed that there may have been a "slug of water" in the fuel line.

A Federal Aviation Administration (FAA) inspector examined the engine. The pilot had fueled the airplane from a nearby gas station. The fuel is placed in a plastic cylindrical gas container and then the airplane is refueled. A visual inspection of the fuel revealed no contamination. The sample of fuel recovered from the filter housing was opaque and cloudy compared to the sample taken from the airplane's header tank. The FAA inspector reported that after cleaning the oil-soaked spark plugs, and installing a fuel filter, he checked the fuel pressure of both pumps at 48 psi, which fell in the normal operating range of the fuel pump. The engine was then started and ran normally, except for a vibration, which was attributed to the broken propeller blades.

Pilot Information

Certificate: Private
Age: 51, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 4-point
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 06/08/2014
Occupational Pilot:
Last Flight Review or Equivalent: 06/05/2013
Flight Time:  (Estimated) 288 hours (Total, all aircraft), 185 hours (Total, this make and model)

Aircraft and Owner/Operator Information

Aircraft Make: CHRISTOPHER TOM
Registration: N533RC
Model/Series: KITFOX  5
Aircraft Category: Airplane
Year of Manufacture: 2001
Amateur Built: Yes
Airworthiness Certificate: Experimental
Serial Number: 0127
Landing Gear Type: Tailwheel
Seats:
Date/Type of Last Inspection: 06/09/2015, Condition
Certified Max Gross Wt.:
Time Since Last Inspection: 27 Hours
Engines: Reciprocating
Airframe Total Time: 342 Hours as of last inspection
Engine Manufacturer: Firewall Forward
ELT: Not installed
Engine Model/Series: CAM 125
Registered Owner: On file
Rated Power: 125 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: SPB, 58 ft msl
Distance from Accident Site: 250 Nautical Miles
Observation Time: 1153 PDT
Direction from Accident Site: 17°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 8 knots /
Turbulence Type Forecast/Actual: /
Wind Direction: 20°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 30.14 inches Hg
Temperature/Dew Point: 16°C / 9°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Battle Ground, WA (NA)
Type of Flight Plan Filed: None
Destination: Battle Ground, WA (NA)
Type of Clearance: None
Departure Time: 1145 PDT
Type of Airspace:

Airport Information

Airport: Private Strip (NA)
Runway Surface Type: Grass/turf
Airport Elevation: 480 ft
Runway Surface Condition: Dry
Runway Used: NA
IFR Approach: None
Runway Length/Width: 2000 ft / 40 ft
VFR Approach/Landing: Forced Landing

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:  45.838333, -122.546667 (est)