Sunday, June 23, 2019

Abrupt Maneuver: Beech E-55 Baron, N6674Y, accident occurred October 05, 2018 at San Antonio International Airport (KSAT), Texas

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; San Antonio, Texas

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


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


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


https://registry.faa.gov/N6674Y

Location: San Antonio, TX
Accident Number: GAA19CA011
Date & Time: 10/05/2018, 1130 CDT
Registration: N6674Y
Aircraft: Beech 55
Aircraft Damage: Substantial
Defining Event: Abrupt maneuver
Injuries: 1 Minor
Flight Conducted Under: Part 91: General Aviation - Personal

Analysis 

The pilot reported that, the day before the accident flight, he had flown the airplane and wanted to become more comfortable with new instruments that had been installed. So, after the flight, while in a hangar, he and a friend turned the airplane's electrical power on to familiarize the pilot with the autopilot system and specifically with how it would follow heading bug settings. During the familiarization, they "ran the [pitch] trim all the way up."

The pilot added that, before takeoff for the accident flight, he did not check the pitch trim setting because he believed it would be the same as his previous flight, instead of the pitch trim setting after his autopilot ground familiarization. He added that, during takeoff, the nose pitched up severely. He lowered the nose, and the airplane entered a negative G condition. He realized that he "did not latch the seat belt very good" and saw that his seatbelt had disconnected and that he was no longer in his seat and could not regain airplane control. The airplane struck the runway, porpoised, and the nose landing gear collapsed. The airplane skidded and struck a taxiway light.

Postaccident examination of the airplane revealed that the vertical trim tab was in the full-down position, indicating that full nose-up trim was applied.

The airplane sustained substantial damage to both engines and the fuselage.

The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.

The Pilot's Operating Handbook checklist titled, "Before Takeoff," stated:

Seat Belts and Shoulder Harnesses – CHECK… 15. Trim – AS REQUIRED FOR TAKE-OFF 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's improper takeoff trim setting and failure to properly secure his seatbelt, which resulted in a loss of airplane control. Contributing to the accident was the pilot's failure to follow the Before Takeoff checklist.

Findings

Aircraft
Elevator tab control system - Incorrect use/operation (Cause)
Flight compartment equipment - Incorrect use/operation (Cause)
Pitch control - Attain/maintain not possible (Cause)

Personnel issues
Aircraft control - Pilot (Cause)
Task monitoring/vigilance - Pilot (Cause)
Use of checklist - Pilot (Factor)

Environmental issues
Runway/taxi/approach light - Contributed to outcome

Factual Information

History of Flight

Prior to flight
Miscellaneous/other

Takeoff
Abrupt maneuver (Defining event)
Abnormal runway contact
Landing gear collapse
Collision with terr/obj (non-CFIT)

Pilot Information

Certificate: Private
Age: 79, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: Lap Only
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 3 Without Waivers/Limitations
Last FAA Medical Exam: 06/21/2017
Occupational Pilot: No
Last Flight Review or Equivalent: 09/20/2015
Flight Time:  (Estimated) 3907 hours (Total, all aircraft), 1322 hours (Total, this make and model), 3897 hours (Pilot In Command, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: Beech
Registration: N6674Y
Model/Series: 55 E55
Aircraft Category: Airplane
Year of Manufacture: 1979
Amateur Built:No 
Airworthiness Certificate: Normal
Serial Number: TE-1168
Landing Gear Type: Retractable - Tricycle
Seats: 6
Date/Type of Last Inspection: 03/20/2017, Annual
Certified Max Gross Wt.: 5324 lbs
Time Since Last Inspection:
Engines: 2 Reciprocating
Airframe Total Time: 5414.5 Hours at time of accident
Engine Manufacturer: Continental
ELT: C91  installed, not activated
Engine Model/Series: IO-520-CB8B
Registered Owner: Arx Inc
Rated Power: 285 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: KSAT, 789 ft msl
Distance from Accident Site: 0 Nautical Miles
Observation Time: 1651 UTC
Direction from Accident Site: 328°
Lowest Cloud Condition: Scattered / 2800 ft agl
Visibility:  10 Miles
Lowest Ceiling:
Visibility (RVR):
Wind Speed/Gusts: 9 knots /
Turbulence Type Forecast/Actual: None / None
Wind Direction: 140°
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 30 inches Hg
Temperature/Dew Point: 29°C / 21°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: San Antonio, TX (SAT)
Type of Flight Plan Filed: None
Destination: San Antonio, TX (SAT)
Type of Clearance: VFR
Departure Time: 1130 CDT
Type of Airspace: Class C 

Airport Information

Airport: SAN ANTONIO INTL (SAT)
Runway Surface Type: Concrete
Airport Elevation: 809 ft
Runway Surface Condition: Dry
Runway Used: 13R
IFR Approach: None
Runway Length/Width: 8502 ft / 150 ft
VFR Approach/Landing: None

Wreckage and Impact Information

Crew Injuries: 1 Minor
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Minor
Latitude, Longitude: 29.538889, -98.480278 (est)

Ground Collision: Cessna 152, N94658, accident occurred October 01, 2018 at Monmouth Executive Airport (KBLM), Belmar, New Jersey

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Saddle Brook, New Jersey

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


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


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

https://registry.faa.gov/N94658

Location: Farmingdale, NJ
Accident Number: GAA19CA003
Date & Time: 10/01/2018, 1015 EDT
Registration: N94658
Aircraft: Cessna 152
Aircraft Damage: Substantial
Defining Event: Ground collision
Injuries: 1 None
Flight Conducted Under: Part 91: General Aviation - Personal

Analysis 

The pilot reported that, while taxiing for departure, the airplane's left wing struck a fuel truck that was parked on the edge of the ramp.

The airplane sustained substantial damage to the left wing.

The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's failure to maintain clearance from a vehicle while taxiing for departure.

Findings

Personnel issues
Task monitoring/vigilance - Pilot (Cause)

Environmental issues
Ground equipment - Effect on operation (Cause)

Factual Information

History of Flight

Taxi
Ground collision (Defining event) 

Pilot Information

Certificate: Private
Age: 71, 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: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 11/03/2016
Occupational Pilot: No
Last Flight Review or Equivalent: 05/21/2018
Flight Time:  (Estimated) 305 hours (Total, all aircraft), 291 hours (Total, this make and model), 185 hours (Pilot In Command, all aircraft), 11 hours (Last 90 days, all aircraft), 5 hours (Last 30 days, all aircraft) 

Aircraft and Owner/Operator Information

Aircraft Make: Cessna
Registration: N94658
Model/Series: 152 No Series
Aircraft Category: Airplane
Year of Manufacture: 1983
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 15285754
Landing Gear Type: Tricycle
Seats: 2
Date/Type of Last Inspection: 02/20/2018, Annual
Certified Max Gross Wt.: 1675 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 10769 Hours at time of accident
Engine Manufacturer: Lycoming
ELT: Installed, activated, did not aid in locating accident
Engine Model/Series: O-235 SERIES
Registered Owner: On file
Rated Power: 110 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: BLM, 164 ft msl
Distance from Accident Site: 0 Nautical Miles
Observation Time: 1456 UTC
Direction from Accident Site: 117°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 7 knots /
Turbulence Type Forecast/Actual: None / None
Wind Direction: 200°
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 30.33 inches Hg
Temperature/Dew Point: 23°C / 17°C
Precipitation and Obscuration:  No Obscuration; No Precipitation
Departure Point: Bowie, MD (W00)
Type of Flight Plan Filed: IFR
Destination: Farmingdale, NJ (BLM)
Type of Clearance: None
Departure Time: 0900 EDT
Type of Airspace: Class G

Airport Information

Airport: MONMOUTH EXECUTIVE (BLM)
Runway Surface Type: Asphalt
Airport Elevation: 153 ft
Runway Surface Condition: Dry
Runway Used: 03
IFR Approach: None
Runway Length/Width: 3508 ft / 50 ft
VFR Approach/Landing: None

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:  40.185000, -74.122222 (est)

Fuel Exhaustion: Jabiru J230-SP, N667J, accident occurred November 18, 2018 in Center, Shelby County, Texas



Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Irving, Texas

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


https://registry.faa.gov/N667J


Location: Center, TX
Accident Number: GAA19CA067
Date & Time: 11/18/2018, 1315 CST
Registration: N667J
Aircraft: JABIRU J230-SP
Aircraft Damage: Substantial
Defining Event: Fuel exhaustion
Injuries: 2 None
Flight Conducted Under: Part 91: General Aviation - Personal 

The pilot reported that prior to departure, he overlooked a NOTAM which identified that fuel was not available at the airport where he had landed and had planned to refuel. He assessed his fuel quantity and departed the airport, subsequently, the engine lost power. He pitched the nose down, the engine regained power, but the pilot realized that the fuel supply was all but exhausted.

He attempted to maintain power and altitude, but eventually selected a field to land. He selected a touchdown point and circled to land, but the airplane did not complete the turn before he had to level the wings. The airplane touched down gently, but the airplane overran the intended landing area, collided with a drainage culvert, and nosed over.

The airplane sustained substantial damage to the composite fuselage and the windscreen.

The pilot determined that he had misinterpreted the manufacturer's pilot operating handbook's declaration of the airplane's total fuel capacity and the airplane's total useable fuel quantity. 

Pilot Information

Certificate: Sport Pilot
Age: 53, 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: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Sport Pilot With Waivers/Limitations
Last FAA Medical Exam:
Occupational Pilot: No
Last Flight Review or Equivalent: 10/30/2017
Flight Time:   (Estimated) 196 hours (Total, all aircraft), 149 hours (Total, this make and model), 151 hours (Pilot In Command, all aircraft), 23 hours (Last 90 days, all aircraft), 20 hours (Last 30 days, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: JABIRU
Registration: N667J
Model/Series: J230-SP
Aircraft Category: Airplane
Year of Manufacture: 2008
Amateur Built: No
Airworthiness Certificate: Special Light-Sport
Serial Number: 574
Landing Gear Type: Tricycle
Seats: 2
Date/Type of Last Inspection: 06/01/2018, Annual
Certified Max Gross Wt.: 1320 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 490 Hours at time of accident
Engine Manufacturer: Jabiru
ELT: Installed, activated, did not aid in locating accident
Engine Model/Series: 3300A
Registered Owner: On file
Rated Power: 120 hp
Operator: On file
Operating Certificate(s) Held: Fractional Ownership

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: F17
Distance from Accident Site:
Observation Time: 1956 UTC
Direction from Accident Site:
Lowest Cloud Condition:
Visibility:  10 Miles
Lowest Ceiling:
Visibility (RVR):
Wind Speed/Gusts: 11 knots /
Turbulence Type Forecast/Actual: /
Wind Direction: 320°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 30.18 inches Hg
Temperature/Dew Point: 14°C / 11°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Mansfield, LA (3F3)
Type of Flight Plan Filed: None
Destination: Center, TX (F17)
Type of Clearance: None
Departure Time: 1300 CST
Type of Airspace: Class G

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: 31.900000, -94.080000 (est)

American Airlines, Boeing 757-200, N938UW: Accident occurred December 31, 2018 in Charlotte, North Carolina

https://registry.faa.gov/N938UW

NTSB Identification: DCA19CA066
Scheduled 14 CFR Part 121: Air Carrier operation of American Airlines
Accident occurred Monday, December 31, 2018 in Charlotte, NC
Aircraft: Boeing 757, registration: N938UW

NTSB investigators will use data provided by various entities, including, but not limited to, the Federal Aviation Administration and/or the operator, and will not travel in support of this investigation to prepare this aircraft accident report.

Loss of Engine Power (Partial): Rans S-12XL, N3165V; accident occurred December 16, 2018 in McClure, Henry County, Ohio


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

Additional Participating Entity: 

Federal Aviation Administration / Flight Standards District Office; Cleveland, Ohio; North Olmsted, Ohio

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/N3165V

Location: McClure, OH
Accident Number: CEN19LA047
Date & Time: 12/16/2018, 1530 EST
Registration: N3165V
Aircraft: Rans S12
Aircraft Damage: Substantial
Defining Event: Loss of engine power (partial)
Injuries:2 None 
Flight Conducted Under: Part 91: General Aviation - Personal 

On December 16, 2018, at 1530 eastern standard time, a Rans Inc. S-12XL experimental light sport airplane, N3165V, experienced a partial loss of engine power during a departure climb from the pilot's private airstrip near McClure, Ohio. The pilot subsequently performed a forced landing to a field about 100 ft north of departure end of the runway after the airplane was unable to maintain a positive climb rate. The private pilot and a passenger were uninjured and the airplane was substantially damaged on impact with terrain. The airplane was registered to and operated by the pilot under Title 14 Code of Federal Regulations Part 91 as a personal flight that was not operating on a flight plan. The local flight was originating at the time of the accident.

The pilot stated that after he performed a walk around inspection of the airplane and loaded the passenger and pushed the airplane outside. He started the airplane in front of hanger and allowed the engine to warm up to 120°F using an engine speed of 3,000 rpm. He taxied about 1,500 feet to the southern end of the north runway, where he performed an engine runup, checked both ignitions, and checked the flight controls. During the takeoff roll, the airplane lifted off the runway about 500 feet down the runway and climbed 50 - 100 ft above ground level at which point engine sound "backed off gradually." He ensured the throttle control was full forward and pumped the throttle control twice, but the engine speed continued to decrease. The pilot decided to perform an off-airport landing on a field which the airplane stuck a powerline pole and the right wing impacted the ground.

Following the accident, the pilot reported the engine, Rotax 582, had low cylinder compression and scoring on the piston and cylinder walls. There were also aluminum fragments within the cylinder. He said that the engine was overhauled about one year prior to his purchase of the airplane by the previous owner. He was "fairly certain" that the engine did not have any problems before the accident flight. The pilot installed a heater that used the engine's cooling system, and on the following flight after the installation, there was a differential exhaust gas temperature between two cylinders, one was high in temperature and the other cylinder was low in temperature. He said that the engine runup after the installation was normal.

The pilot stated a thermostat was installed on the coolant system and coolant was used for cabin heat. He said the engine radiator was not covered for cold weather operation. He felt the piston failure was due to cold seizure.

According to the Rotax 2-Stroke Maintenance Schedule, the Rotax 582 engine had a minimum coolant temperature of 150°F.

An Ultralight News article discussed cold seizures occurring in Rotax 532/582 engines by coolant having been cooling in the radiator, in winter in cold temperatures, which can mean that the temperature is down below 100°F. The engine on the other hand is under load and is creating heat, the pistons are expanding. As the cold liquid enters the area around the cylinders, the cylinder shrink and this causes a cold seizure.

The Federal Aviation Administration Aviation (FAA) Safety Inspector from the Cleveland Flight Standards District Office stated the pilot reported that an engine cylinder compression check was not performed when he purchased the airplane, and a cylinder compression check was not performed during the last condition inspection of the airplane. The engine was not examined by the FAA, and the engine manufacturer declined to attend an examination. 

Pilot Information

Certificate: Private
Age: 51, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
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 Without Waivers/Limitations
Last FAA Medical Exam: 11/24/2017
Occupational Pilot: No
Last Flight Review or Equivalent: 03/30/2018
Flight Time:  192 hours (Total, all aircraft), 30 hours (Total, this make and model), 192 hours (Pilot In Command, all aircraft), 9 hours (Last 90 days, all aircraft), 2 hours (Last 30 days, all aircraft) 

Aircraft and Owner/Operator Information

Aircraft Make: Rans
Registration: N3165V
Model/Series: S12 XL
Aircraft Category: Airplane
Year of Manufacture: 2000
Amateur Built: No
Airworthiness Certificate: Experimental
Serial Number: 04284
Landing Gear Type: Tricycle
Seats: 2
Date/Type of Last Inspection: 05/01/2018, Condition
Certified Max Gross Wt.: 975 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 115 Hours at time of accident
Engine Manufacturer: Rotax
ELT: Not installed
Engine Model/Series: 582
Registered Owner: Pilot
Rated Power: 65 hp
Operator:Pilot 
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: USE, 781 ft msl
Distance from Accident Site: 12 Nautical Miles
Observation Time: 1330 EST
Direction from Accident Site: 145°
Lowest Cloud Condition: Clear
Visibility:  9 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 3 knots /
Turbulence Type Forecast/Actual: None / None
Wind Direction: Variable
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 30.01 inches Hg
Temperature/Dew Point: 6°C / 6°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point:  MCCLURE, OH (PVT)
Type of Flight Plan Filed: None
Destination: MCCLURE, OH (PVT)
Type of Clearance: None
Departure Time: 2030 EST
Type of Airspace:

Airport Information

Airport: Private (PVT)
Runway Surface Type: Grass/turf
Airport Elevation: 677 ft
Runway Surface Condition: Dry
Runway Used: 36
IFR Approach: None
Runway Length/Width: 1200 ft / 60 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: 41.371111, -83.942222 (est)

Location: MCCLURE, OH
Accident Number: CEN19LA047
Date & Time: 12/16/2018, 1530 EST
Registration: N3165V
Aircraft: Rans S12
Injuries: 1 None
Flight Conducted Under: Part 91: General Aviation - Personal 

On December 16, 2018, at 1530 eastern standard time, a Rans Inc. S-12XL, N3165V, experienced a partial loss of engine power during a departure climb from runway 36 at the pilot's private airstrip near McClure, Ohio. The pilot performed a forced landing to a field about 100 feet north of departure end of the runway after the airplane was unable to maintain a positive climb rate. The airplane sustained substantial damage on impact with terrain. The private pilot and a passenger were uninjured. The airplane was registered to and operated by the pilot under Title 14 Code of Federal Regulations Part 91 as a personal flight that was not operating on a flight plan. The local flight was originating at the time of the accident and was to return to the departure airport upon completion of the flight.

Post-accident examination of the airplane engine revealed low cylinder compression of the engine and scoring of the piston and cylinder walls. No other anomalies were noted.

Aircraft and Owner/Operator Information

Aircraft Make: Rans
Registration: N3165V
Model/Series: S12 XL
Aircraft Category: Airplane
Amateur Built: No
Operator: Pilot
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: USE, 781 ft msl
Observation Time: 1330 EST
Distance from Accident Site: 12 Nautical Miles
Temperature/Dew Point: 6°C / 6°C
Lowest Cloud Condition: Clear
Wind Speed/Gusts, Direction: 3 knots / , Variable
Lowest Ceiling: None
Visibility:  9 Miles
Altimeter Setting: 30.01 inches Hg
Type of Flight Plan Filed: None
Departure Point: MCCLURE, OH (PVT)
Destination: MCCLURE, OH (PVT) 

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: 41.371389, -83.941944 (est)