Wednesday, August 07, 2019

Loss of Control on Ground: Glasair II, N181AL; accident occurred July 15, 2017 at Meadow Lake Airport (KFLY), Colorado Springs, El Paso County, Colorado

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

Additional Participating Entity:

Federal Aviation Administration / Flight Standards District Office; Denver, Colorado

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/N181AL

Location: Colorado Springs, CO
Accident Number: CEN17LA274
Date & Time: 07/15/2017, 1300 MDT
Registration: N181AL
Aircraft: Endler Glasair/Glasair 1-TD SH2
Aircraft Damage: Destroyed
Defining Event: Loss of control on ground
Injuries: 2 None
Flight Conducted Under: Part 91: General Aviation - Personal 

On July 15, 2017, about 1300 mountain daylight time, an experimental amateur-built Endler Glasair SH2 (Glasair 1-TD), N181AL, ground looped and veered off runway 15 (6,000 feet by 60 feet, asphalt) during takeoff from Meadow Lake Airport (FLY), Colorado Springs, Colorado. The airplane impacted a taxiway light and was destroyed by fire. The pilot and passenger were uninjured. The airplane was registered to and operated by an individual under 14 Code of Federal Regulations Part 91 as a personal flight that was not operating on a flight plan. Visual meteorological conditions prevailed at the time of the accident. The local flight was originating at the time of the accident.

The pilot stated that the airport automated weather observing system reported winds from 050 degrees at 7 knots, which was a "direct crosswind" to runways 15 and 33. The pilot decided to use runway 15 because an American Champion Decathlon or Citabria airplane "just landed" on runway 15, and runway 15 was the "favored runway" for the airport. The pilot said that there was a 1-2 knot tailwind for the accident takeoff. During the takeoff roll on runway 15, the airplane "continued to creep" to the left side of the runway even with application of [right] brake and rudder. The pilot made "one last big effort" to return the airplane to runway centerline, by "swerving." The airplane veered toward the left and off the runway surface. The airplane ground looped and a fire ensued from the right main landing gear well.

Post-accident examination of witness marks along runway 15 revealed a mark consistent with continued application of right main landing gear wheel brake. The airplane veered off the runway about 2,400 down the runway and struck a taxiway light. The grass area located about 10-20 feet preceding the taxiway light exhibited burning. The right main landing gear was collapsed under the fuselage. The airplane was equipped with a castering tailwheel with a locking pin. The tailwheel was not a steerable assembly.

The pilot said that the normal takeoff distance for the airplane was about 1,000 feet and when asked why the airplane impacted about 2,400 feet down the runway, he said "I don't know." He said that he discussed this in his analysis of the statement he provided. He said maybe it was an engine issue and did not know what the engine rpm was at the time of takeoff.

The airplane owner's manual states that the tailwheel locks in the straight position for takeoff and landing. In the unlocked position, the tailwheel full swivels 360 degrees. The airplane checklist states that the tailwheel is to be in the locked position for takeoff.

The National Transportation Safety Board Investigator-in-Charge asked the pilot what the maximum demonstrated crosswind velocity was for the airplane and the airplane's center of gravity (CG) location for the flight; the pilot said that he did not know the velocity and would check with the airplane owner and try to obtain the weight and balance form. The pilot said that based on the owner's information, the maximum demonstrated cross wind for the airplane was 15 knots. The pilot said his personal maximum crosswind velocity limit was 10 knots.

The airplane owner's manual does not cite a maximum demonstrated crosswind velocity but a recommended velocity of 20 mph.

The pilot said that the airplane weight and balance form was in the airplane and destroyed by the fire. The CG location for the flight could not be determined. The pilot said that the accident takeoff weight was about 470 lbs. He said that the fuel and passenger locations are roughly the moment arm from the airplane CG, so all weight has the same CG effect. 

Pilot Information

Certificate: Airline Transport; Flight Instructor
Age: 43, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): Airplane Single-engine; Instrument Airplane
Toxicology Performed: No
Medical Certification: Class 2 Without Waivers/Limitations
Last FAA Medical Exam:
Occupational Pilot: Yes
Last Flight Review or Equivalent: 04/13/2017
Flight Time:  3400 hours (Total, all aircraft), 20 hours (Total, this make and model), 3000 hours (Pilot In Command, all aircraft), 50 hours (Last 90 days, all aircraft), 25 hours (Last 30 days, all aircraft), 1 hours (Last 24 hours, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: Endler Glasair/Glasair 1-TD
Registration: N181AL
Model/Series: SH2
Aircraft Category: Airplane
Year of Manufacture: 1988
Amateur Built: Yes
Airworthiness Certificate: Experimental
Serial Number: 181
Landing Gear Type: Tailwheel
Seats: 2
Date/Type of Last Inspection: 04/06/2017, Condition
Certified Max Gross Wt.: 1600 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 1151.6 Hours as of last inspection
Engine Manufacturer: Lycoming
ELT: Installed, not activated
Engine Model/Series: O-320-E2A
Registered Owner: Individual
Rated Power:
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: FLY, 6874 ft msl
Distance from Accident Site: 0 Nautical Miles
Observation Time: 1315 MDT
Direction from Accident Site:
Lowest Cloud Condition: Clear
Visibility: 10 Miles
Lowest Ceiling: None 
Visibility (RVR):
Wind Speed/Gusts: 6 knots / 16 knots
Turbulence Type Forecast/Actual: / None
Wind Direction: 30°
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 30.43 inches Hg
Temperature/Dew Point: 23°C / 12°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Colorado Springs, CO (FLY)
Type of Flight Plan Filed: None
Destination: Colorado Springs, CO (FLY)
Type of Clearance: None
Departure Time: 1300 MDT
Type of Airspace: Class G

Airport Information


Airport: Meadow Lake Airport (FLY)
Runway Surface Type: Asphalt
Airport Elevation: 6873 ft
Runway Surface Condition: Dry
Runway Used: 15
IFR Approach: None
Runway Length/Width: 6000 ft / 60 ft
VFR Approach/Landing: None 

Wreckage and Impact Information


Crew Injuries: 1 None
Aircraft Damage: Destroyed
Passenger Injuries: 1 None
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 None
Latitude, Longitude: 38.945833, -104.570000 (est)

Fuel Starvation: Cessna 172M Skyhawk, N80457; accident occurred July 13, 2017 in Key Biscayne, Miami-Dade 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; Miramar, Florida

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/N80457


Location: Key Biscayne, FL
Accident Number: ERA17LA242
Date & Time: 07/13/2017, 2320 EDT
Registration: N80457
Aircraft:CESSNA 172 
Aircraft Damage: Substantial
Defining Event: Fuel starvation
Injuries: 1 Minor, 1 None
Flight Conducted Under: Part 91: General Aviation - Instructional 

On July 13, 2017, about 2320 eastern daylight time, a Cessna 172M, N80457, was substantially damaged during a forced landing to a road near Key Biscayne, Florida. The flight instructor was not injured and the private pilot receiving instruction sustained minor injuries. The airplane was being operated under the provisions of 14 Code of Federal Regulations Part 91 as an instructional flight. Night visual meteorological conditions prevailed at the time and no flight plan was filed for the flight which originated from Miami Executive Airport (TMB), Miami, Florida, about 2055.

The flight instructor stated that during the preflight inspection, both fuel tanks were visually inspected and also checked using a dipstick, and each tank contained about 15 gallons. The flight departed TMB with the fuel selector on the "both" position, and flew to Fort Lauderdale Executive Airport (FXE), Fort Lauderdale, Florida, where the private pilot, who was receiving instruction for an instrument rating, executed a practice instrument approach that terminated with a full-stop landing. The airplane remained on the ground for about 15-18 minutes with the engine operating, then departed and flew to Palm Beach International Airport (PBI), West Palm Beach, Florida, where the private pilot executed another practice instrument approach, which terminated with a missed approach, and holding practice. About 2215, the flight instructor elected to return to TMB and requested visual flight rules flight following from air traffic control (ATC). The flight proceeded south, east to the coast, and then south along the shoreline. While flying near Key Biscayne with the engine operating between 2,300 and 2,350 rpm, the mixture control full rich, and the fuel selector on the same position it had been since the initial takeoff (both), the engine sputtered for about 2-3 seconds, lost power, then increased briefly to 1,500 rpm, before losing power again. The private pilot reported the left and right fuel gauges at that time were indicating in the lower red arc and between 1/4 and 1/2 capacity, respectively. Attempts to restore engine power consisted of moving the fuel selector to each fuel tank position, and checking the magnetos on each respective position, but engine power was not restored. The flight instructor declared an emergency with the ATC controller and requested assistance from emergency equipment. While descending for a forced landing to a road, the airplane collided with tree branches, and then a light pole, and came to rest within 25 to 30 ft of the touchdown point on the road.

According to a Federal Aviation Administration inspector, there was no evidence of fuel leakage or a breach of either fuel tank. Less than 1 gallon of fuel was drained from the left fuel tank, while about 10 gallons of fuel were drained from the right fuel tank. The airplane was recovered for further examination at a later date.

Examination of the airplane following recovery revealed the right fuel tank strainer, part number 0422130 was nearly completely blocked by organic material. 



Flight Instructor Information

Certificate: Airline Transport; Flight Instructor; Commercial
Age: 30, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s): None
Restraint Used: Lap Only
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): Airplane Multi-engine; Airplane Single-engine; Instrument Airplane
Toxicology Performed: No
Medical Certification: Class 1 Without Waivers/Limitations
Last FAA Medical Exam: 01/04/2017
Occupational Pilot:Yes 
Last Flight Review or Equivalent: 07/27/2016
Flight Time:  2800 hours (Total, all aircraft), 510 hours (Total, this make and model), 2750 hours (Pilot In Command, all aircraft), 300 hours (Last 90 days, all aircraft), 75 hours (Last 30 days, all aircraft), 3 hours (Last 24 hours, all aircraft)



Student Pilot Information

Certificate: Private
Age: 23, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None 
Restraint Used: Lap Only
Instrument Rating(s): None
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 1 Without Waivers/Limitations
Last FAA Medical Exam: 11/14/2016
Occupational Pilot: No
Last Flight Review or Equivalent: 04/08/2017
Flight Time:  164 hours (Total, all aircraft), 21 hours (Total, this make and model), 127 hours (Pilot In Command, all aircraft), 111 hours (Last 90 days, all aircraft), 55 hours (Last 30 days, all aircraft) 




Aircraft and Owner/Operator Information

Aircraft Make: CESSNA
Registration: N80457
Model/Series: 172 M
Aircraft Category: Airplane
Year of Manufacture:
Amateur Built: No
Airworthiness Certificate: Normal; Utility
Serial Number: 17266596
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection: 06/30/2017, 100 Hour
Certified Max Gross Wt.: 2300 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 5547.8 Hours at time of accident
Engine Manufacturer: LYCOMING
ELT: C91  installed, activated, aided in locating accident
Engine Model/Series: O-320-E2D
Registered Owner: C & G AIRCRAFT PARTS, INC.
Rated Power: 150 hp
Operator: Dean International, Inc.
Operating Certificate(s) Held: Pilot School (141)
Operator Does Business As: Dean International Flight School
Operator Designator Code:



Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Night
Observation Facility, Elevation: MIA, 9 ft msl
Distance from Accident Site: 9 Nautical Miles
Observation Time: 2253 EDT
Direction from Accident Site: 306°
Lowest Cloud Condition: Few / 1500 ft agl
Visibility:  10 Miles
Lowest Ceiling: Broken / 25000 ft agl
Visibility (RVR):
Wind Speed/Gusts: 10 knots /
Turbulence Type Forecast/Actual: / None
Wind Direction: 100°
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 30.08 inches Hg
Temperature/Dew Point: 28°C / 25°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: West Palm Beach, FL (PBI)
Type of Flight Plan Filed: None
Destination: Miami, FL (TMB)
Type of Clearance: VFR Flight Following
Departure Time:  EDT
Type of Airspace: 

Wreckage and Impact Information

Crew Injuries: 1 Minor, 1 None
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Minor, 1 None
Latitude, Longitude: 25.710278, -80.155833

Fuel Related: Cessna P206A Super Skylane, N206TF; accident occurred June 12, 2017 near Eagles Nest Airport (31E), West Creek, Ocean County, New Jersey

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

Additional Participating Entity:

Federal Aviation Administration / Flight Standards District Office; Philadelphia, 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/N206TF




Location: West Creek, NJ
Accident Number: ERA17LA205
Date & Time: 06/12/2017, 2255 EDT
Registration: N206TF
Aircraft: CESSNA P206
Aircraft Damage: Substantial
Defining Event: Fuel related
Injuries: 1 Minor
Flight Conducted Under: Part 91: General Aviation - Other Work Use

On June 12, 2017, about 2255 eastern daylight time, a Cessna P206A, N206TF, was substantially damaged during a forced landing while on approach to Eagles Nest Airport (31E), West Creek, New Jersey. The commercial pilot sustained minor injuries. The airplane was being operated under the provisions of 14 Code of Federal Regulations Part 91 as a post-maintenance flight. Visual meteorological conditions prevailed at the time and a visual flight rules flight plan was filed but not activated for the flight that originated about 1 hour earlier from Danbury Municipal Airport (DXR), Danbury, Connecticut.

Two days earlier, 4 repaired cylinders were installed on the airplane's engine that required break-in. In preparation of the flight to break-in the cylinders, the pilot personally spoke with the mechanic and was given the procedures, which included operation of the engine at full rich, and to monitor the cylinder head temperature (CHT). He was also informed to check the fuselage belly for fresh oil. The pilot reported he personally filled both fuel tanks, bringing the total usable capacity in each tank to 31.5 gallons. He then flew the airplane on an uneventful 1 hour flight from 31E to DXR. The entire flight was performed with the fuel selector on the right tank, the mixture control in the full rich position, and the engine operating at 24 inches manifold pressure and 2,400 rpm. No engine discrepancies were noted during the flight, and no fuel was purchased while at DXR.

Prior to departing DXR for the return flight to 31E, the pilot stated that he performed a "quick preflight inspection", and although the airplane was equipped with a dipstick to check the fuel quantity, he did not use it during his preflight inspection. The airplane departed with the fuel selector on the left tank position, the mixture control in the full rich position, and climbed at full power to 7,500 ft mean sea level (msl). The pilot maintained 24 inches manifold pressure and 2,400 rpm (same engine settings as the first leg), and flew to 31E while periodically scanning the engine gauges. While on final approach to runway 14, he realized the "sight picture" was not correct, and performed a go-around. He climbed to between 1,000 and 1,200 ft msl, then turned onto the crosswind and downwind legs of the airport traffic pattern. While on the downwind leg of the airport traffic pattern between 1,200 and 1,500 ft msl, before midfield, with the auxiliary fuel pump on, the engine sputtered and quit, and the propeller stopped. The pilot attempted to restart the engine which consisted of moving the fuel selector to the right tank position, verifying the mixture control was full rich, and advancing the throttle, but the engine did not restart. He turned onto the base leg of the airport traffic pattern, and flew towards the runway while maintaining best glide speed of 80 knots; however, the airplane impacted trees then the ground about 1/4 nautical mile before the runway, and came to rest inverted. The fuel selector was not moved before exiting the airplane.

Postaccident examination of the airplane by a Federal Aviation Administration (FAA) inspector revealed the fuel selector was positioned to the left fuel tank. About 2.5 gallons of fuel were drained from it which was breached in 2 locations, while about 6 ounces of fuel were drained from the un-breached right fuel tank. The ground beneath the left wing smelled of fuel, while the ground beneath the right fuel tank did not smell of fuel, and no fuel blight to vegetation was noted beneath the right fuel tank. No fuel stains were noted aft of either fuel cap. One propeller blade was slightly bent.

Examination of the airplane by the same FAA inspector following recovery revealed fuel was present at the inlet and outlet of the auxiliary fuel pump, but no fuel was present at the inlet or outlet of the engine-driven fuel pump, or at the flow divider/manifold valve. With battery power applied, and a fuel supply provided, the auxiliary fuel pump provided fuel to the inlet and outlet of the engine-driven fuel pump. This was repeated with the fuel selector positioned to the left and right tank positions. There were no reported issues with the aircraft's fuel system. The propeller was rotated by hand and with a spark plug removed from each cylinder, suction and compression was noted in each cylinder. Also during hand rotation, the magnetos produced spark at all spark plugs. A temporary fuel supply was plumbed into the aircraft's fuel system, and the engine was started and operated for about 12 seconds. Safety concerns prevented a prolonged run or operation at a high power setting. No discrepancies were noted during the engine run.

Pilot Information

Certificate: Commercial
Age: 36, 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 1 Without Waivers/Limitations
Last FAA Medical Exam: 09/30/2016
Occupational Pilot: Yes
Last Flight Review or Equivalent: 04/09/2017
Flight Time:  1050 hours (Total, all aircraft), 20 hours (Total, this make and model), 930 hours (Pilot In Command, all aircraft), 89 hours (Last 90 days, all aircraft), 61 hours (Last 30 days, all aircraft), 8 hours (Last 24 hours, all aircraft) 

Aircraft and Owner/Operator Information

Aircraft Make: CESSNA
Registration: N206TF
Model/Series: P206 A
Aircraft Category: Airplane
Year of Manufacture:
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: P206-0289
Landing Gear Type: Tricycle
Seats: 2
Date/Type of Last Inspection: 03/08/2017, 100 Hour
Certified Max Gross Wt.: 3600 lbs
Time Since Last Inspection: 34 Hours
Engines: 1 Reciprocating
Airframe Total Time: 11950.8 Hours as of last inspection
Engine Manufacturer: Continental
ELT: Installed, not activated
Engine Model/Series: IO-520-A
Registered Owner: On file
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: Not Reported
Observation Facility, Elevation: MJX, 86 ft msl
Distance from Accident Site: 16 Nautical Miles
Observation Time: 2256 EDT
Direction from Accident Site: 2°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 4 knots /
Turbulence Type Forecast/Actual: / None
Wind Direction: 240°
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 29.99 inches Hg
Temperature/Dew Point: 24°C / 18°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Danbury, CT (DXR)
Type of Flight Plan Filed: VFR
Destination: West Creek, NJ (31E)
Type of Clearance: None
Departure Time: 2200 EDT
Type of Airspace:

Airport Information

Airport: Eagles Nest Airport (31E)
Runway Surface Type: N/A
Airport Elevation: 39 ft
Runway Surface Condition: Unknown
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: Forced Landing; Traffic Pattern

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: 39.667778, -74.309167 (est)

Fire (Non-Impact): Cessna U206F, N9575G; accident occurred May 22, 2017 in Noatak, Alaska

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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Fairbanks, Alaska
Textron Aviation; Wichita, Kansas

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/N9575G


Location: Noatak, AK
Accident Number: ANC17LA024
Date & Time: 05/22/2017, 1823 AKD
Registration: N9575G
Aircraft: CESSNA U206F
Aircraft Damage: Destroyed
Defining Event: Fire/smoke (non-impact)
Injuries: 2 None
Flight Conducted Under: Part 135: Air Taxi & Commuter - Non-scheduled

On May 22, 2017, about 1823 Alaska daylight time, a Cessna U206F airplane, N9575G, was destroyed following a fire while taxiing, after landing at a remote unimproved off airport landing site near Noatak, Alaska. The airplane was registered to and operated by Golden Eagle Outfitters, as a visual flight rules flight under the provisions of 14 Code of Federal Regulations Part 135 when the accident occurred. The certificated commercial pilot and one passenger were not injured. Visual meteorological conditions prevailed, and company flight following procedures were in effect. The flight departed Ralph Wein Memorial Airport (OTZ), Kotzebue, Alaska at about 1800.

The pilot reported that after landing, at the remote unimproved off-airport landing site, he taxied to the end of the strip and turned around while raising the airplane's flaps. Immediately thereafter, he felt heat on the left side of his face, he glanced out the left side pilot window, and then turned his head to the right, when he noticed flames in the aft cabin near the right-side cargo door. Both the pilot and passenger immediately exited the airplane. The pilot stated that he attempted to regain access to the burning airplane through the right-side cargo door but was unable due to the heat and flames.

The passenger provided a list of items that were onboard the airplane at the time of the accident, that included, in part: two duffel bags with personal and camping gear, two action packers with camp food and research supplies, two sealed packages of AA and AAA alkaline batteries, two laptop computers equipped with lithium batteries, a partial can of Coleman camp stove fuel and camp stove, a sealed 12-volt battery, field shovel, soil probe and stream flow meter.

A review of the airplanes maintenance records revealed that on March 11, 2017, the right main fuel bladder had been replaced and a new fuel bladder assembly installed with new gaskets and clips. In addition, the fuel selector was replaced with a rebuilt fuel selector.

On July 13, 2017, the NTSB IIC, along with a Federal Aviation Administration safety inspector from the Fairbanks Flight Standards District Office and a representative from Textron Aviation examined the airframe and engine at the facilities of Alaska Claims Services, Inc., Wasilla, Alaska.

The cockpit, baggage area, right wing, left wing fuel cell and fuselage section forward of the vertical stabilizer, along with the contents of the airplane were largely consumed by fire.

The fuel selector was located and exhibited extensive thermal damage. The fuel lines were melted through, however, all the B-nuts attaching the aluminum fuel lines to the fuel selector appeared to be in place.

Pilot Information

Certificate: Commercial
Age: 35, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): Airplane Single-engine
Toxicology Performed: No
Medical Certification: Class 2 Without Waivers/Limitations
Last FAA Medical Exam: 12/31/2016
Occupational Pilot:Yes 
Last Flight Review or Equivalent: 02/27/2017
Flight Time:  9300 hours (Total, all aircraft), 5000 hours (Total, this make and model), 9300 hours (Pilot In Command, all aircraft), 259 hours (Last 90 days, all aircraft), 70 hours (Last 30 days, all aircraft), 3 hours (Last 24 hours, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: CESSNA
Registration: N9575G
Model/Series: U206F
Aircraft Category: Airplane
Year of Manufacture: 1972
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: U20601775
Landing Gear Type: Tricycle
Seats:
Date/Type of Last Inspection: 05/01/2017, Annual
Certified Max Gross Wt.:
Time Since Last Inspection:
Engines: Reciprocating
Airframe Total Time: 14189 Hours as of last inspection
Engine Manufacturer: Continental
ELT: C126 installed, activated, aided in locating accident
Engine Model/Series: IO-520
Registered Owner: GOLDEN EAGLE OUTFITTERS
Rated Power: 300 hp
Operator: GOLDEN EAGLE OUTFITTERS
Operating Certificate(s) Held: On-demand Air Taxi (135)

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: PATZ
Distance from Accident Site: 38 Nautical Miles
Observation Time: 0158 UTC
Direction from Accident Site: 10°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 9 knots /
Turbulence Type Forecast/Actual:
Wind Direction: 280°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 29.71 inches Hg
Temperature/Dew Point: 13°C / -3°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Kotzebue, AK
Type of Flight Plan Filed: Company VFR
Destination: Noatak, AK
Type of Clearance: None
Departure Time: 1800 AKD
Type of Airspace: Class G

Wreckage and Impact Information

Crew Injuries: 1 None
Aircraft Damage: Destroyed
Passenger Injuries: 1 None
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 None
Latitude, Longitude: 68.471389, -162.225000 (est)

Powerplant System / Component Malfunction / Failure: Robinson R44 Astro, N981RR; accident occurred May 05, 2017 in Santa Barbara, California

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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Van Nuys, California
Lycoming Engines; Williamsport, Pennsylvania
Robinson Helicopter Company; Torrance, California

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/N981RR


Location: Santa Barbara, CA
Accident Number: WPR17LA097
Date & Time: 05/05/2017, 1402 PDT
Registration: N981RR
Aircraft: ROBINSON HELICOPTER R44
Aircraft Damage: Destroyed
Defining Event: Powerplant sys/comp malf/fail
Injuries: 3 Serious
Flight Conducted Under: Part 91: General Aviation - Personal - Sightseeing 

On May 5, 2017, at 1402 Pacific daylight time, a Robinson R44 helicopter, N981RR, lost engine power and landed hard following an autorotation near Santa Barbara, California. The flight instructor and two passengers sustained serious injuries, and the helicopter was destroyed by post impact fire. The helicopter was registered to Spitzer Helicopter LLC, and operated by Santa Barbara Helicopter Tours, as a revenue sightseeing flight under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan had been filed. The local flight departed Santa Barbara Municipal Airport, Santa Barbara, California, about 1345.

The flight was planned to be a standard 20 minute, "City Tour" for the two passengers, which included a roundtrip flight from the airport to the Santa Barbara Zoo area, about 10 miles east.

The outbound flight was uneventful with the pilot requesting a special VFR (visual flight rules) clearance due to low cloud ceilings. On the return leg, the weather had not improved, and the pilot requested a special VFR clearance to land. The airport controllers directed the pilot to hold outside of the airport's airspace due to landing traffic, and the pilot circled the city for about 10 minutes until the landing request was granted. He then proceeded to follow the 101 Highway west towards the airport, and a brief time later he noticed that the engine began to lose partial power, coincident with the clutch actuator light illuminating. He pulled the clutch actuator circuit breaker while evaluating his landing options. He began to maneuver the helicopter for landing at a golf course, rather than the highway or congested areas below, and a few seconds later the engine lost all power.

He immediately initiated an autorotation, with the intention of landing on the golf course. During the final stage of the descent, he realized he would not be able to reach the grass due to a wall, so he landed just short in a parking lot. During the landing flare, the helicopter's main rotor blades struck the roof of a building, and the helicopter landed hard, spreading both skids (See Figure 1). All occupants egressed from the helicopter, while the golf course superintendent, who heard the impact, attempted to extinguish a fire which had developed at the rear of the helicopter's fuselage. Within a few minutes the fire had spread, ultimately engulfing the main cabin as the local fire department arrived about 5 minutes later.

Multiple witnesses reported seeing an object fall from the helicopter as it flew over the highway, and post-accident examination revealed that the engines number 3 cylinder head assembly and piston were missing (See Figure 2). A search was conducted by volunteer search and rescue personnel from the Santa Barbara County Sherriff's Department, and the assembly was located the following day, in a field about 1/4 mile north of the wreckage location (See Figure 3).


Figure 1 - Helicopter at the Accident Site

Figure 2 - Helicopter at the Accident Site with Cylinder #3 Missing

Figure 3 - Cylinder #3 

Pilot Information

Certificate: Flight Instructor; Commercial
Age: 40, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s): Helicopter
Restraint Used:
Instrument Rating(s): Helicopter
Second Pilot Present: No
Instructor Rating(s): Helicopter
Toxicology Performed: No
Medical Certification: Class 2 Without Waivers/Limitations
Last FAA Medical Exam: 02/22/2017
Occupational Pilot: Yes
Last Flight Review or Equivalent: 02/22/2017
Flight Time:  1520 hours (Total, all aircraft), 944 hours (Total, this make and model), 1419 hours (Pilot In Command, all aircraft), 98 hours (Last 90 days, all aircraft), 20 hours (Last 30 days, all aircraft), 1 hours (Last 24 hours, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: ROBINSON HELICOPTER
Registration: N981RR
Model/Series: R44
Aircraft Category: Helicopter
Year of Manufacture: 2001
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 0961
Landing Gear Type: Ski;
Seats: 4
Date/Type of Last Inspection: 04/06/2017, Continuous Airworthiness
Certified Max Gross Wt.: 2200 lbs
Time Since Last Inspection: 36.5 Hours
Engines: 1 Reciprocating
Airframe Total Time: 3709 Hours at time of accident
Engine Manufacturer: LYCOMING
ELT: Not installed
Engine Model/Series: O-540
Registered Owner: SPITZER HELICOPTER LLC
Rated Power: 260 hp
Operator: Santa Barbara Helicopter Tours
Operating Certificate(s) Held: Commercial Air Tour (136); On-demand Air Taxi (135)
Operator Does Business As: Santa Barbara Helicopter Tours
Operator Designator Code: 9D3A 



Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KSBA, 20 ft msl
Distance from Accident Site: 5 Nautical Miles
Observation Time: 1353 PDT
Direction from Accident Site: 265°
Lowest Cloud Condition:
Visibility:  10 Miles
Lowest Ceiling: Overcast / 800 ft agl
Visibility (RVR):
Wind Speed/Gusts: 3 knots /
Turbulence Type Forecast/Actual:
Wind Direction: 240°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 29.9 inches Hg
Temperature/Dew Point: 14°C / 12°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: SANTA BARBARA, CA (SBA)
Type of Flight Plan Filed: None
Destination: SANTA BARBARA, CA (SBA)
Type of Clearance: Special VFR
Departure Time: 1345 PDT
Type of Airspace: Class C



Wreckage and Impact Information

Crew Injuries: 1 Serious
Aircraft Damage: Destroyed
Passenger Injuries: 2 Serious
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 3 Serious
Latitude, Longitude: 34.432778, -119.751111

Tests And Research

Engine Examination

The engine was disassembled following the accident by technical representatives from Lycoming Engines under the supervision of the NTSB investigator-in-charge, and inspectors from the Federal Aviation Administration (FAA). Complete examination reports are contained in the public docket, the following is a summary of findings.

The engine remained attached to the aft frame support assembly and the forward engine mounts. It sustained extensive thermal damage, partially consuming most of its ancillary components.

The entire number 3 cylinder assembly had separated from the engine, and neither its pushrods were recovered. The lower section of the crankcase deck adjacent to the underside of cylinder 3, along with the entire oil sump was consumed by fire.

The crankshaft could be viewed through the opening, and was intact. The number 3 connecting rod remained attached to the crankshaft, and protruded from the opening. The outboard (piston) end of the rod was not present.

The engine was examined for evidence of signatures typically associated with overspeed, as defined in Lycoming Service Bulletin SB369N. The valves, springs, and rocker arm assemblies for each cylinder were intact and undamaged. The valves slid easily out of their valve guides, and did not exhibit any indications of valve head "mushrooming" or burs to the areas in contact with the valve keys. The valve keys and exhaust valve caps were all undamaged, and the remaining pushrods were straight. The camshaft was intact, and all lobes and bearing surfaces were shiny in appearance and free of score marks.

The oil filter had sustained thermal damage and was removed from the housing and disassembled. The filter element was black and charred, and contained bronze-colored non-ferrous metallic debris similar in appearance to connecting rod (piston-end) bushing material.



Materials Laboratory Examination

The engine crankcase, 6 connecting rod wrist pins, 12 wrist pin plugs, the through bolts, main crankshaft bearings, and the number 3 and 4 cylinder and piston assemblies were sent to the NTSB Materials Laboratory for examination.

Examination revealed that the number 3 cylinder attachment studs and throughbolts all exhibited varying combinations and degrees of necking damage, smearing deformation, and rough and matte gray fracture features, all of which were consistent with ductile overstress.

The damaged number 3 connecting rod had fractured just short of the bushing, which was missing. The corresponding piston was mostly intact, and the wrist pin was in place. The piston had multiple impact marks on the underside surfaces and piston skirt. The skirt was deformed inward at the forward and aft sides, trapping the piston within the cylinder barrel.

A segment of the upper side of the piston skirt was fractured and missing, and a similar shaped segment of the skirt at the lower side of the barrel was fractured and flattened against the cylinder attachment flange. The damage to both segments was consistent with contact with the number 3 connecting rod.

At the upper side of the cylinder flange, the attachment holes were elongated. The location of the hole elongation was consistent with the direction of shear deformation observed in the corresponding studs. At the lower side of the cylinder, the flange was bent, and cracked though the middle two attachment holes. The cracks were associated with deformation consistent with ductile overstress fracture.

Most of the number 3 cylinder attachment flange around the attachment holes appeared dark gray, but portions of the flange were either coated in an orange oxidized layer, or appeared light gray and smeared. Machining marks were visible around most of the surfaces, including many of the oxidized areas.

The crankcase was separated to reveal the mating sides of the crankcase halves. The mating surfaces had a smooth, polished appearance with scattered pits. Similar pit features were also observed on other machined surfaces including the saddle surfaces supporting the main journal bearings and the camshaft journal bore surfaces.

The connecting rod for cylinder 3 was fractured where the wrist pin bore intersected the beam section of the rod. A curved impact mark was observed on the outboard end of the connecting rod. The shape of the impact mark was consistent with the inboard end of the cylinder barrel skirt at the "6 o'clock" position. The rod end surfaces were obliterated by post-fracture contact damage, and fine features of the fractures were mostly obliterated by oxidation. Remaining fracture surfaces were visually smooth with sliding contact marks, consistent with ductile overstress fracture in compressive shear loading. Elongated dimple features were observed on remaining fracture surfaces, also consistent with ductile overstress fracture.

The outboard ends of the number 2, 4, and 6 connecting rods had a bright blue color, and a slight blue tint was also noted at the outboard ends of connecting rods 1 and 5.

The wrist pins from cylinders 1, 2, 4, 5, and 6 were mostly free of mechanical damage, but were tinted brown, bluish gray, and black consistent with heat exposure. By comparison, the number 3 wrist pin had mechanical damage in the area corresponding to the connecting rod attachment and was light gray in color across most of the surface. Bushings in three of the connecting rods had shifted out of position laterally, and in two cases, the bushing split line had rotated from its installed position by about 45o.

Examination of the inboard and outboard surfaces of the number 3 wrist pin revealed a bluish gray circumferential tint band on one side where it intersected the boss on the piston, and a brown circumferential tint band adjacent to the other boss. Circumferential gouges and galling were present on the surface between the two tint bands. A longitudinal mark with galled material was present on the outboard side of the wrist pin.

Maintenance History

According to the last entry in the maintenance records on April 6, 2017, the engine had accumulated 1,473 hours of flight time since a Lycoming factory rebuild in 2011. The engine tachometer was destroyed in the fire, but according to the operator, the helicopter had accumulated an additional 36.5 hours during that time.

The records indicated that the oil system was serviced in accordance with Lycoming Engines Mandatory Service Bulletin SB-480E, which required oil changes at 50-hour intervals along with a check for premature or excessive engine component wear, indicated by the presence of metal particles, shavings, or flakes in the oil filter element or screens. The last oil change took place on April 1, 2017, 39.8 hours before the accident, and the logbook entry specifically noted that the oil filter and screens were examined at that time.

SB-480E stated that Lycoming encourages the use of spectrograph oil analysis to monitor engine component wear rates.

No oil from the engine was ever sent for spectrographic analysis, and there was no evidence to indicate the connecting rods or connecting rod bushings were changed since the engine was rebuilt.

Maintenance Bulletins and Directives

Lycoming Engines Mandatory Service Bulletin SB-630, subject, "Connecting Rod Bushing Inspection After Cylinder Removal" was issued about one month before the accident on April 10, 2017. It applied to all Lycoming engines, and required the inspection of the connecting rod bushing for indications that it had shifted out of position. Compliance was mandated at the next maintenance event that required cylinder removal.

Mandatory Service Bulletin SB-632, subject, "Identification of Connecting Rods with Non-Conforming Small End Bushings" was issued July 17, 2017 and subsequently updated to SB-632B on August 4, 2017. The bulletin called for identification and replacement of connecting rod bushings. Compliance was required within 10 hours of engine operation; however, the accident engine was not one of the models affected by the bulletin. The FAA mandated compliance with SB-632B by issuing Airworthiness Directive AD 2017-16-11, on August 15, 2017.

According to Airworthiness Bulletin AWB 85-020 Issue 3, issued by the Civil Aviation Safety Authority of Australia (CASA), all Lycoming reciprocating aircraft engines which were new, factory rebuilt, or factory overhauled during the 2011 calendar year were susceptible to premature wear of the connecting rod bushings. The bulletin noted that in both those engines, and all engines referenced in SB-632B, one or more bushings may shift axially during operation, leading to wear of the protruding edge of the bushing against the piston. The bulletin further stated that the development of this premature wear condition is relatively slow and predictable, and that regular oil and oil filter inspections have shown to be effective in detecting this condition.

Representatives from Lycoming Engines stated that they had no evidence to corroborate the findings of AWB 85-020 regarding 2011 calendar year engines. Specifically, that there were no changes to systems, process, or materials that would explain the failures related to 2011-year engines operating in Australia. Furthermore, the FAA did not find evidence that would have necessitated the release of a similar directive in the United States.

The helicopter was fitted with the fuel tank bladders required in Robinson Helicopters Service Bulletin SB-78B