Robert V. Burkhart
Roger D. Lundeen
The National Transportation Safety Board traveled to the scene of this accident.
Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Springfield, Illinois
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/N94070
Location: Monmouth, IL
Accident Number: CEN18FA235
Date & Time: 06/24/2018, 1115 CDT
Registration: N94070
Aircraft: ERCOUPE 415 D
Aircraft Damage: Destroyed
Defining Event: Loss of engine power (total)
Injuries: 2 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal
On June 24, 2018, about 1115 central daylight time, an Ercoupe 415-D airplane, N94070, impacted terrain near Monmouth Municipal Airport (C66), Monmouth, Illinois. The private pilot and pilot-rated passenger were fatally injured and the airplane was destroyed. The airplane was registered to and operated by a private individual under to 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 for the local flight, which departed Galesburg Municipal Airport (GBG) Galesburg, Illinois, at 1049.
Airport surveillance video from GBG revealed that the airplane taxied from the hangar area toward the end of runway 21 at 1044. The airplane then taxied along the parallel taxiway to the first intersection where it made a left 180° turn and taxied back to the end of runway 21. The airplane departed runway 21 at 1049.
A review of the radar data revealed that the airplane traveled west after departure from GBG. The radar track showed the airplane made several turns and continued west toward C66. The final radar target was recorded about 2 miles south of the accident site (see figure 1). A review of the GBG common traffic advisory frequency (CTAF) recording revealed that, at 1103, the pilot announced his intentions to complete a touch-and-go landing at C66.
Figure 1 – Radar Track (end of flight)
A witness, who was on a golf course about 0.3 mile south of the accident site, stated that he saw the airplane flying north about 1100. He stated that "the engine sounded like it was missing and not flying smoothly." He added that the airplane continued north behind trees, which obstructed his view, but he listened to the engine sound for another 15 to 30 seconds, then he "heard the engine rev higher." The airplane's reported northbound flight path over the golf course was consistent with a left downwind leg for runway 21 at C66.
Two other witnesses, who were 1/2 mile northeast of C66, stated that the airplane was traveling east to west and flew very low over their house and the engine was "sputtering and backfiring." They stated that the airplane flew about 30 ft above them, made a steep left bank, then impacted the ground in a wooded area (see figure 2). After impact, the airplane burst into flames. They both ran to the accident site to provide assistance but were unable to help due to the fire and extreme heat.
Figure 2 – Accident Site
Pilot Information
Certificate: Private
Age: 65, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): None
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 06/06/2016
Occupational Pilot: No
Last Flight Review or Equivalent: 08/13/2016
Flight Time: (Estimated) 361.5 hours (Total, all aircraft)
Pilot-Rated Passenger Information
Certificate: Private
Age: 72, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): None
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 08/06/2015
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time: (Estimated) 775 hours (Total, all aircraft)
The most recent pilot logbook entry, dated March 8, 2018, was for a 1.5-hour local flight from GBG in the accident airplane. The two previous logbook entries were dated July 2017, which were also local flights in the accident airplane.
Aircraft and Owner/Operator Information
Aircraft Make: ERCOUPE
Registration: N94070
Model/Series: 415 D
Aircraft Category: Airplane
Year of Manufacture: 1946
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 1393
Landing Gear Type: Tricycle
Seats: 2
Date/Type of Last Inspection: 10/19/2017, Annual
Certified Max Gross Wt.: 1400 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 4135.4 Hours as of last inspection
Engine Manufacturer: Continental Motors
ELT: Installed, not activated
Engine Model/Series: O-200A
Registered Owner: On file
Rated Power: 100 hp
Operator: On file
Operating Certificate(s) Held: None
Fuel records showed that the airplane was most recently fueled on March 8, 2018, with 11 gallons of 100 low-lead aviation gasoline. How much fuel was onboard the airplane before the fuel was added or whether the airplane had been fueled at any other time since March 8, 2018, could not be determined.
Meteorological Information and Flight Plan
Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: GBG, 804 ft msl
Distance from Accident Site: 9 Nautical Miles
Observation Time: 1115 CDT
Direction from Accident Site: 92°
Lowest Cloud Condition: Scattered / 2800 ft agl
Visibility: 10 Miles
Lowest Ceiling:
Visibility (RVR):
Wind Speed/Gusts: Calm /
Turbulence Type Forecast/Actual: /
Wind Direction:
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 29.96 inches Hg
Temperature/Dew Point: 26°C / 18°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Monmouth, IL (C66)
Type of Flight Plan Filed: None
Destination: Monmouth, IL (C66)
Type of Clearance: None
Departure Time: 1049 CDT
Type of Airspace: Class E
Airport Information
Airport: MONMOUTH MUNI (C66)
Runway Surface Type: Asphalt
Airport Elevation: 753 ft
Runway Surface Condition: Unknown
Runway Used: 21
IFR Approach: None
Runway Length/Width: 2899 ft / 60 ft
VFR Approach/Landing: Unknown
Wreckage and Impact Information
Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 1 Fatal
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: On-Ground
Total Injuries: 2 Fatal
Latitude, Longitude: 40.938611, -90.623056 (est)
A postaccident examination of the airframe revealed that the fuselage was consumed by fire. The empennage remained intact with minor impact and fire damage at the rear fuselage area. The metal structure of both wings remained mostly intact and the fabric covering was consumed by fire. The two wing fuel tanks and the header fuel tank were consumed by fire. The header tank fuel quantity gauge was found in the debris path and the metal rod was bent near the cork end. The elevator and rudder control cables remained intact and were continuous from the cockpit to the control surfaces. The aileron control tubes and associated hardware were intact from the ailerons through the wing to the fuselage; both aileron control tubes were fractured and bent near the fuselage.
The engine came to rest inverted and remained attached to the engine mounts and the firewall. The two-blade, fixed-pitch propeller was attached to the crankshaft. One propeller blade was bent aft near mid-span and the other blade was straight with minimal damage. Neither propeller blade exhibited leading edge damage or chordwise scratches. The propeller was rotated by hand and engine continuity was confirmed through the valve train and rear accessory section; the cylinders exhibited suction and compression with the top spark plugs removed. The carburetor had separated from the engine but was sitting on the engine; the carburetor sustained fire and impact damage. The throttle cable remained attached to the throttle control arm. The mixture control cable was loose from mixture control arm and was found immediately next to the carburetor.
Although fire and impact damage to the engine limited the scope of the examination, no preimpact mechanical malfunctions or anomalies were found that would have precluded normal operation.
Medical And Pathological Information
The Warren Country Coroner's Office, Monmouth, Illinois, performed autopsies on the pilot and passenger. The pilot's cause of death was attributed to thermal injuries and the inhalation of products of combustion.
The pilot-rated passenger's autopsy revealed severe coronary artery disease with 75% stenosis of the mid right coronary artery and 75% stenosis of the proximal left anterior descending coronary artery. No thromboemboli were noted. No evidence of a recent or past heart attack was noted. The cerebral and pulmonary circulations were unremarkable. There was no obvious anatomic evidence of an incapacitating event. The passenger's cause of death was attributed to the blunt force injuries.
The Federal Aviation Administration's (FAA) Forensic Sciences Laboratory performed toxicological testing on the pilot and passenger. The pilot's toxicology detected three previously reported (during his FAA medical exam) medications: chlorthalidone, irbesartan, and carvedilol, none of which are considered impairing. Also present was naproxen, which is available in two formulations, prescription and over-the-counter (OTC). Prescription naproxen is used to relieve pain, tenderness, swelling, and stiffness caused by osteoarthritis, rheumatoid arthritis, ankylosing spondylitis and other similar conditions. OTC naproxen is used to reduce fever and to relieve mild pain. Naproxen is in a class of medications called non-steroidal anti-inflammatory drug, and use would generally not present a hazard to aviation safety.
The passenger's toxicology detected no medications, illicit drugs, ethanol, or products of combustion that could pose hazards to flight safety.
Keith and Dawn Curtis
The National Transportation Safety Board traveled to the scene of this accident.
Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Kansas City, Missouri
Piper Aircraft; Vero Beach, Florida
Lycoming aircraft engines; Williamsport, 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/N6433J
Location: Reeds Spring, MO
Accident Number: CEN18FA054
Date & Time: 12/17/2017, 1830 CST
Registration: N6433J
Aircraft: PIPER PA28
Aircraft Damage: Destroyed
Defining Event: VFR encounter with IMC
Injuries: 2 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal
On December 17, 2017, about 1830 central standard time, a Piper PA-28-180 airplane, N6433J, impacted terrain near Reeds Spring, Missouri. The pilot and passenger were fatally injured, and the airplane was destroyed. The airplane was registered to and operated by a private individual, as a Title 14 Code of Federal Regulations Part 91 personal fight. Night instrument meteorological conditions prevailed near the accident site about the time of the accident, and no flight plan was filed. The cross-country flight departed Gardner Municipal Airport (K34), Gardner, Kansas, about 1700, and was en route to M. Graham Clark Downtown Airport (PLK), Branson, Missouri.
The pilot was not in communication with air traffic control during the accident flight; however, review of radar information revealed a flight track that correlated with the time and location of accident airplane. The airplane approached the Branson area from the north/northwest, making several turns including circles, before the target disappeared from radar near the accident site. While en route, the flight reached a maximum altitude of 2,750 ft mean sea level (msl); however, the flight's average altitude was about 2,500 ft msl. The last several radar returns showed the airplane at an altitude of 2,250 ft msl, 2,125 ft msl, and 2,200 ft msl, with the last radar return at 2,050 ft msl, in altitude, and just east of the accident site. The terrain elevation in the immediate area of the accident site, was about 1,300-1,400 ft. msl.
Several witnesses reported hearing the airplane overhead or circling before the engine went quiet, followed by the sound of a crash. First responders were notified and responded to the accident site. Both the witnesses and first responders reported the weather about the time of the accident was foggy with poor visibility.
PERSONNEL INFORMATION
The pilot held a private pilot certificate with rating for airplane single-engine land. A review of Federal Aviation Administration (FAA) records did not find any information that the pilot held an instrument rating. His most recent third-class FAA medical certificate was issued on February 17, 2017, with the limitation: "shall possess glasses for near/intermediate vision." At the time of the exam, the pilot reported 0 total flight hours and 0 hours in the previous six months. The pilot's logbook was not available for review; however, family members estimated that the pilot had accumulated about 100 total hours of flight time.
The passenger held a student pilot certificate. Her third-class FAA medical certificate was issued on March 16, 2017, with a limitation for corrective lenses.
AIRCRAFT INFORMATION
The accident airplane was a Piper PA-28-180, which is a low-wing, all metal, single-engine airplane with fixed landing gear, powered by a 180-horsepower Lycoming four-cylinder engine, and a fixed-pitch propeller. A review of the airplane's maintenance records revealed the last annual inspection was completed on June 5, 2017, at an airplane tachometer time of 4,550.9 hours and 231.8 hours since engine overhaul. A previous annual inspection, dated September 22, 2012, listed a tachometer time of 4,538.42 hours and a time since engine overhaul of 219.37 hours. A review of FAA records showed that the pilot purchased the airplane on June 10, 2017.
METEOROLOGICAL INFORMATION
At 1835, the Branson West Municipal Airport – Emerson Field (FWB), Branson, Missouri, automated weather observation station (AWOS), located about 1.5 miles south of the accident site, recorded calm wind, 1/2-mile visibility, 400-ft overcast ceiling, temperature 46°F, dew point 46°F, and an altimeter setting of 30.08 inches of mercury.
At 1845, the Branson Airport (BBG), Branson, Missouri, AWOS, located about 14.7 miles southeast of the accident site, recorded calm wind, 1 3/4-miles visibility with mist, 200-ft overcast ceiling, temperature 45°F, dew point 45°F, and an altimeter setting of 30.08 inches of mercury.
At 1655 (about the time the flight departed from K34), the FWB AWOS recorded calm wind, 1/2-mile visibility and fog, and a 400 ft overcast ceiling. At 1645, the BBG AWOS recorded calm wind, 3/4-mile visibility in mist, and a 200-ft overcast ceiling.
At 1555, (about an hour before departure from K34) the FWB AWOS recorded calm wind, 3/4-mile visibility in mist, and a 300-ft overcast ceiling. At 1545, BBG AWOS recorded calm wind, 3/4-mile visibility in mist, and a 300-ft overcast ceiling.
The National Weather Service Springfield, Missouri Weather Forecast Office is responsible for the Branson area, but does not issue a Terminal Aerodrome Forecast (TAF) for PLK. The closest TAF to the accident site was issued for BBG.
A terminal aerodrome forecast (TAF) for BBG was issued before the pilot's departure at 1700 and called for light instrument flight rules (LIFR) conditions to prevail with variable wind at 5 knots, 3 miles visibility in mist, and an overcast ceiling at 400 ft above ground level (agl). The two subsequent amendments and the next scheduled TAF also called for LIFR conditions, with visibility deteriorating to 3/4 mile and an overcast ceiling at 300 ft agl.
The NTSB Meteorology Weather Study Report is in the docket for this accident.
There was no record of the pilot obtaining weather briefing.
AIRPORT INFORMATION
PLK is a non-towered, public airport located 1 mile south of Branson, Missouri. The airport has a single asphalt runway oriented 12/30, which is 3,738 ft long by 100 ft wide. Runways 12 and 30 are equipped with RNAV (GPS) instrument approaches.
There are several public airports in the Branson area, including BBG located 6 miles south of PLK, and has an operating control tower and instrument approaches.
FWB is non-towered airport, located 2 miles west of Branson West, Missouri. FWB has RNAV (GPS) instrument approaches to runway 03 and 12
WRECKAGE AND IMPACT INFORMATION
The accident site was located in an open field in a rural neighborhood, about 1.5 miles north of FWB and about 11 miles northwest of PLK.
The on-scene examination of the wreckage and ground scars revealed the airplane impacted terrain in a near-vertical, nose-down attitude. The airplane came to rest near the initial impact point, with the engine and airplane nose buried in a small crater. Several fragments of the airplane were scattered from the impact point and all major components were accounted for at the accident site. There was no evidence of a postcrash fire.
Both wings displayed accordion-type crush damage along their entire span; the main cabin was severely crushed, and the empennage also displayed heavy impact damage. Both wing fuel tanks were breached.
Due to damage, the position of the wing flaps could not be determined; however, the flap cable remained attached to the selector handle. The avionics, instruments, gauges, and cockpit controls were impact-damaged and unreadable. The attitude indicator was removed and examined; the gyro displayed scoring from contact with its housing, consistent with operation at the time of impact.
Left and right wing aileron control cable continuity was established from the aileron bell crank to the chain segment in the cockpit. The chain had separated from the yoke control bar, consistent with overload due to impact forces.
The rudder, stabilator, and pitch trim control cables remained attached to their respective control surfaces and were continuous to the recovery separation cuts. The pitch trim jackscrew was extended about 4-5 threads above the cable drum, consistent with a neutral trim tab position.
The engine sustained impact damage, with the crankshaft broken just aft of the No. 1 main bearing journal, which had separated from the engine. The damage to the crankshaft and camshaft prevented manual engine rotation; a visual inspection of the valve train and the accessory section was conducted. The carburetor was broken from its intake flange. The float bowl and fuel inlet screen were free of contaminants and no pre-impact abnormalities were noted. The carburetor floats exhibited crushing consistent with hydraulic deformation. The oil screen was removed and was clear of contaminants. Both magnetos were impact fragmented. The vacuum pump was removed and disassembled; the internal vanes and rotor were broken, consistent with impact forces.
The top sparkplugs were removed, and the plugs exhibited light colored combustion deposits. The electrodes exhibited normal wear signatures.
The fixed pitch two-bladed propeller remained attached to the crankshaft flange. Both blades exhibited leading edge gouging and polishing.
Although the examination was limited due to impact damage, no pre-impact abnormalities were noted during the airframe or engine examinations.
Pilot Information
Certificate: Private
Age: 52
Airplane Rating(s): Single-engine Land
Seat Occupied: Unknown
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): None
Second Pilot Present:
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 02/17/2017
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time: 100 hours (Total, all aircraft)
Dawn Curtis
Pilot-Rated Passenger Information
Certificate: Student
Age: 45
Airplane Rating(s): Single-engine Land
Seat Occupied: Unknown
Other Aircraft Rating(s):
Restraint Used:
Instrument Rating(s):
Second Pilot Present:
Instructor Rating(s):
Toxicology Performed: Yes
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 03/16/2017
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time:
Aircraft and Owner/Operator Information
Aircraft Make: PIPER
Registration: N6433J
Model/Series: PA28 180
Aircraft Category: Airplane
Year of Manufacture:
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 28-4851
Landing Gear Type: Tricycle
Seats:
Date/Type of Last Inspection: 06/05/2017, Annual
Certified Max Gross Wt.:
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 4550.9 Hours as of last inspection
Engine Manufacturer: LYCOMING
ELT: Installed, not activated
Engine Model/Series: O-360 SER
Registered Owner: On file
Rated Power: 180 hp
Operator: On file
Operating Certificate(s) Held: None
Meteorological Information and Flight Plan
Conditions at Accident Site: Instrument Conditions
Condition of Light: Night
Observation Facility, Elevation: KFWB
Distance from Accident Site: 1 Nautical Miles
Observation Time: 0035 UTC
Direction from Accident Site: 360°
Lowest Cloud Condition:
Visibility:
Lowest Ceiling: Overcast / 400 ft agl
Visibility (RVR):
Wind Speed/Gusts: Calm /
Turbulence Type Forecast/Actual:
Wind Direction:
Turbulence Severity Forecast/Actual:
Altimeter Setting: 30.08 inches Hg
Temperature/Dew Point: 8°C / 8°C
Precipitation and Obscuration: Moderate - Fog
Departure Point: Gardner, KS (K34)
Type of Flight Plan Filed: None
Destination: Branson, MO (KPLK)
Type of Clearance: None
Departure Time: 1700 CST
Type of Airspace:
Wreckage and Impact Information
Crew Injuries: 2 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Fatal
Latitude, Longitude: 36.724722, -93.396111 (est)
Medical And Pathological Information
The Stone County, Missouri, Medical Examiner's Office conducted autopsies on the two occupants. The causes of death were determined to be blunt injuries.
The FAA's Forensic Sciences laboratory at Oklahoma City, Oklahoma, conducted toxicological testing on both occupants. The specimens were not tested for carbon monoxide and cyanide. Specimens of the pilot were positive for ethanol in the liver and negative for tested drugs. The passenger tested positive for ethanol in muscle but negative in the brain. The test was also negative for tested drugs.
The levels of ethanol and finding in one tissue, but not another, is consistent with post-mortem production of ethanol.
Steve Paulus
The National Transportation Safety Board traveled to the scene of this accident.
Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Cleveland FSDO; North Olmsted, Ohio
Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf
http://registry.faa.gov/N2200T
Location: Ravenna, OH
Accident Number: CEN18FA045
Date & Time: 12/03/2017, 1140 EST
Registration: N2200T
Aircraft: PIPER TITAN TORNADO II D
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal
Analysis
The sport pilot of the experimental, amateur-built airplane was returning to the airport after a 30-minute flight. A witness saw the airplane on final approach to the runway about 500 ft above ground level when he heard a total loss of engine power. The airplane banked left and right and entered a nose-down descent consistent with an aerodynamic stall condition. The airplane impacted terrain short of the runway.
Although the witness, an acquaintance of the accident pilot, estimated that the pilot had accrued about 10 hours of flight time in the airplane since purchasing it about 1 year prior, the pilot's logbook was not located during the investigation, and his experience level in the accident airplane could not be determined. Additionally, it could not be determined if the pilot had obtained transition training in the accident airplane, which was classified as a low-inertia/high-drag airplane. Low-inertia/high-drag airplanes rapidly lose energy (airspeed and/or altitude) when there is a loss or reduction of power, and are particularly susceptible to unintentional aerodynamic stalls due to their low cruise speed to stall speed margin and their tendency to experience significant airspeed decay with increased load factor (such as during a turn).
Examination of the airplane and engine revealed no mechanical anomalies that would have precluded normal operation; therefore, the reason for the loss of engine power could not be determined. It is likely that the pilot failed to attain a proper airspeed following the loss of engine power, which resulted in an exceedance of the airplane's critical angle of attack, an aerodynamic stall, and impact with terrain.
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 adequate airspeed following a loss of engine power during final approach for landing, which resulted in an exceedance of the airplane's critical angle of attack and an aerodynamic stall.
Findings
Aircraft
Angle of attack - Attain/maintain not possible (Cause)
Airspeed - Not attained/maintained (Cause)
Personnel issues
Aircraft control - Pilot (Cause)
Factual Information
History of Flight
Approach-VFR pattern final
Loss of engine power (total)
Loss of control in flight (Defining event)
Uncontrolled descent
Collision with terr/obj (non-CFIT)
On December 3, 2017, at 1140 eastern standard time, an experimental, amateur-built Titan Tornado II D, N2200T, impacted terrain while on final approach for landing at Portage County Airport (POV), Ravenna, Ohio. The sport pilot sustained fatal injuries, and the airplane was destroyed by impact forces. The airplane was owned by the pilot who was operating it as a Title 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed at the time of the accident and no flight plan was filed for the flight, which departed from POV about 1110.
The only witness to the accident stated that the pilot stopped by the witness's hangar before the accident flight and said that it was a beautiful day to go flying. The witness saw the airplane take off from runway 27 and described the takeoff as "Learjet style," meaning that the airplane had a high rate of climb. The airplane proceeded south until it disappeared from his view. The witness subsequently saw the accident airplane on final approach for runway 27 about 30 minutes later. While on final approach, the airplane was "coming down normally and regularly" before he heard the engine noise "suddenly stop" and the engine went "silent." About 10 seconds later and about 1 mile from the approach end of runway 27, the airplane started "acting erratically." The airplane banked right, then banked immediately left, and then banked right before descending from about 500 ft above ground level into the ground. The witness stated that the airplane "didn't go straight down," but it was a "steep" descent.
Pilot Information
Certificate: Sport Pilot
Age: 60, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Front
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Sport Pilot Without Waivers/Limitations
Last FAA Medical Exam:
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time:
The pilot held a sport pilot certificate. He also held repairman-experimental aircraft builder and repairman-light sport aircraft certificates. The pilot's logbook was not available for review. The pilot did not hold an FAA airman medical certificate, nor was he required to as a sport pilot.
Aircraft registration records showed that the pilot purchased the airplane on September 10, 2016.The witness estimated that the pilot had accumulated about 10 hours in the airplane since purchasing it.
Aircraft and Owner/Operator Information
Aircraft Make: PIPER
Registration: N2200T
Model/Series: TITAN TORNADO II D
Aircraft Category: Airplane
Year of Manufacture: 2017
Amateur Built: Yes
Airworthiness Certificate: Experimental
Serial Number: 002
Landing Gear Type: Tricycle
Seats: 2
Date/Type of Last Inspection: 02/06/2017, Condition
Certified Max Gross Wt.:
Time Since Last Inspection: 0 Hours
Engines: 1 Reciprocating
Airframe Total Time: as of last inspection
Engine Manufacturer: Jabiru
ELT:
Engine Model/Series: 2200
Registered Owner: Individual
Rated Power: 85 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: POV, 1198 ft msl
Distance from Accident Site: 1 Nautical Miles
Observation Time: 1133 EDT
Direction from Accident Site: 270°
Lowest Cloud Condition: Clear
Visibility: 10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 5 knots /
Turbulence Type Forecast/Actual: / None
Wind Direction: 270°
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 30.22 inches Hg
Temperature/Dew Point: 6°C / 0°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Ravenna, OH (POV)
Type of Flight Plan Filed: None
Destination: Ravenna, OH (POV)
Type of Clearance: None
Departure Time: 1110 EST
Type of Airspace:
Airport Information
Airport: Portage County Airport (POV)
Runway Surface Type: Asphalt
Airport Elevation: 1198 ft
Runway Surface Condition: Dry
Runway Used: 27
IFR Approach: None
Runway Length/Width: 3499 ft / 75 ft
VFR Approach/Landing:
Wreckage and Impact Information
Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 41.208611, -81.228333 (est)
The wreckage was located behind a house about 0.8 mile east of runway 27. The area surrounding the wreckage displayed ground scarring consistent with the dimensions of the airplane. The airplane was oriented in a nose-down attitude. The wings, elevators, and rudder and their respective controls surfaces were attached and secure. The propeller was attached and secure to the engine, which remained attached to the airframe. Neither of the two propeller blades displayed damage. There was no evidence of fire or sooting. The instrument panel was destroyed by impact forces.
Flight control continuity was established from the flight control surfaces to the cockpit controls. Engine control continuity from the cockpit controls to the engine was confirmed.
The 15-gallon fuel tank contained an estimated 1 gallon of liquid consistent with fuel. The fuel did not exhibit contamination. The fuel valves from the fuel tank to the engine were in the open position.
The airplane was equipped with an Adventure Pilot iFly 720 multi-function display and GPS unit with removable SD card; a MGL RDAC XB module that was designed to interface thermocouples and other engine monitoring sensors, which was connected to an Electronic Flight Instrument System (EFIS); and a MGL XL (non-Stratomaster model) EFIS. These units were sent to the National Transportation Safety Board Recorders Laboratory for download of non-volatile memory. The last data log retrieved from the Adventure Pilot iFly 720 had a timestamp from October 21, 2017, about 2.5 months before the accident flight. The MGL RDAC XB and MGL XL units did not record data.
The engine, a Jabiru model 2200 (serial number 22A3748), was removed and shipped to Arion Aircraft, Shelbyville, Tennessee, for an engine run under the supervision of an FAA inspector. The inspector stated that the engine started and ran smoothly for about 5 to 10 minutes before the test was discontinued.
Medical And Pathological Information
The Cuyahoga County Medical Examiner's Office, Cleveland, Ohio, performed an autopsy of the pilot. The medical examiner reported the cause of death as blunt impact injuries.
Toxicology testing performed by the FAA Forensic Sciences Laboratory identified Losartan in liver. Testing was negative for ethanol and carbon monoxide.
Losartan is a prescription medication used primarily for the treatment of high blood pressure. It may be used alone or in combination with other antihypertensive agents. It is not considered to be impairing.
Tests And Research
Advisory Circular (AC) 90-109A, Transition to Unfamiliar Aircraft, discusses training and risk mitigation in flying various families of airplanes.
According to a table found in Appendix 2 of the AC, the Titan Tornado II was categorized as a low-inertia and/or high-drag airplane. Appendix 4 of the AC defined low-inertia and/or high-drag airplanes as airplanes that rapidly lose energy (airspeed and/or altitude) when there is a loss or reduction of power.
In addition, Appendix 4 d. Other Hazards, states,
Hazards of low-inertia/high-drag airplanes are not limited to power management issues. While all airplanes experience an increase in stall speed with an increase in load factor, such as during turns, these airplanes may also experience significant airspeed decay with increased load factor. This, coupled with low cruise speed to stall speed margin, make these airplanes particularly susceptible to unintentional stalls.
Location: Ravenna, OH
Accident Number: CEN18FA045
Date & Time: 12/03/2017, 1140 EST
Registration: N2200T
Aircraft: PIPER TITAN TORNADO II D
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal
Analysis
The sport pilot of the experimental, amateur-built airplane was returning to the airport after a 30-minute flight. A witness saw the airplane on final approach to the runway about 500 ft above ground level when he heard a total loss of engine power. The airplane banked left and right and entered a nose-down descent consistent with an aerodynamic stall condition. The airplane impacted terrain short of the runway.
Although the witness, an acquaintance of the accident pilot, estimated that the pilot had accrued about 10 hours of flight time in the airplane since purchasing it about 1 year prior, the pilot's logbook was not located during the investigation, and his experience level in the accident airplane could not be determined. Additionally, it could not be determined if the pilot had obtained transition training in the accident airplane, which was classified as a low-inertia/high-drag airplane. Low-inertia/high-drag airplanes rapidly lose energy (airspeed and/or altitude) when there is a loss or reduction of power, and are particularly susceptible to unintentional aerodynamic stalls due to their low cruise speed to stall speed margin and their tendency to experience significant airspeed decay with increased load factor (such as during a turn).
Examination of the airplane and engine revealed no mechanical anomalies that would have precluded normal operation; therefore, the reason for the loss of engine power could not be determined. It is likely that the pilot failed to attain a proper airspeed following the loss of engine power, which resulted in an exceedance of the airplane's critical angle of attack, an aerodynamic stall, and impact with terrain.
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 adequate airspeed following a loss of engine power during final approach for landing, which resulted in an exceedance of the airplane's critical angle of attack and an aerodynamic stall.
Findings
Aircraft
Angle of attack - Attain/maintain not possible (Cause)
Airspeed - Not attained/maintained (Cause)
Personnel issues
Aircraft control - Pilot (Cause)
Factual Information
History of Flight
Approach-VFR pattern final
Loss of engine power (total)
Loss of control in flight (Defining event)
Uncontrolled descent
Collision with terr/obj (non-CFIT)
On December 3, 2017, at 1140 eastern standard time, an experimental, amateur-built Titan Tornado II D, N2200T, impacted terrain while on final approach for landing at Portage County Airport (POV), Ravenna, Ohio. The sport pilot sustained fatal injuries, and the airplane was destroyed by impact forces. The airplane was owned by the pilot who was operating it as a Title 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed at the time of the accident and no flight plan was filed for the flight, which departed from POV about 1110.
The only witness to the accident stated that the pilot stopped by the witness's hangar before the accident flight and said that it was a beautiful day to go flying. The witness saw the airplane take off from runway 27 and described the takeoff as "Learjet style," meaning that the airplane had a high rate of climb. The airplane proceeded south until it disappeared from his view. The witness subsequently saw the accident airplane on final approach for runway 27 about 30 minutes later. While on final approach, the airplane was "coming down normally and regularly" before he heard the engine noise "suddenly stop" and the engine went "silent." About 10 seconds later and about 1 mile from the approach end of runway 27, the airplane started "acting erratically." The airplane banked right, then banked immediately left, and then banked right before descending from about 500 ft above ground level into the ground. The witness stated that the airplane "didn't go straight down," but it was a "steep" descent.
Pilot Information
Certificate: Sport Pilot
Age: 60, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Front
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Sport Pilot Without Waivers/Limitations
Last FAA Medical Exam:
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time:
The pilot held a sport pilot certificate. He also held repairman-experimental aircraft builder and repairman-light sport aircraft certificates. The pilot's logbook was not available for review. The pilot did not hold an FAA airman medical certificate, nor was he required to as a sport pilot.
Aircraft registration records showed that the pilot purchased the airplane on September 10, 2016.The witness estimated that the pilot had accumulated about 10 hours in the airplane since purchasing it.
Aircraft and Owner/Operator Information
Aircraft Make: Paul A Piper
Registration: N2200T
Model/Series: TITAN TORNADO II D
Aircraft Category: Airplane
Year of Manufacture: 2017
Amateur Built: Yes
Airworthiness Certificate: Experimental
Serial Number: 002
Landing Gear Type: Tricycle
Seats: 2
Date/Type of Last Inspection: 02/06/2017, Condition
Certified Max Gross Wt.:
Time Since Last Inspection: 0 Hours
Engines: 1 Reciprocating
Airframe Total Time: as of last inspection
Engine Manufacturer: Jabiru
ELT:
Engine Model/Series: 2200
Registered Owner: Individual
Rated Power: 85 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: POV, 1198 ft msl
Distance from Accident Site: 1 Nautical Miles
Observation Time: 1133 EDT
Direction from Accident Site: 270°
Lowest Cloud Condition: Clear
Visibility: 10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 5 knots /
Turbulence Type Forecast/Actual: / None
Wind Direction: 270°
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 30.22 inches Hg
Temperature/Dew Point: 6°C / 0°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Ravenna, OH (POV)
Type of Flight Plan Filed: None
Destination: Ravenna, OH (POV)
Type of Clearance: None
Departure Time: 1110 EST
Type of Airspace:
Airport Information
Airport: Portage County Airport (POV)
Runway Surface Type: Asphalt
Airport Elevation: 1198 ft
Runway Surface Condition: Dry
Runway Used: 27
IFR Approach: None
Runway Length/Width: 3499 ft / 75 ft
VFR Approach/Landing:
Wreckage and Impact Information
Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 41.208611, -81.228333 (est)
The wreckage was located behind a house about 0.8 mile east of runway 27. The area surrounding the wreckage displayed ground scarring consistent with the dimensions of the airplane. The airplane was oriented in a nose-down attitude. The wings, elevators, and rudder and their respective controls surfaces were attached and secure. The propeller was attached and secure to the engine, which remained attached to the airframe. Neither of the two propeller blades displayed damage. There was no evidence of fire or sooting. The instrument panel was destroyed by impact forces.
Flight control continuity was established from the flight control surfaces to the cockpit controls. Engine control continuity from the cockpit controls to the engine was confirmed.
The 15-gallon fuel tank contained an estimated 1 gallon of liquid consistent with fuel. The fuel did not exhibit contamination. The fuel valves from the fuel tank to the engine were in the open position.
The airplane was equipped with an Adventure Pilot iFly 720 multi-function display and GPS unit with removable SD card; a MGL RDAC XB module that was designed to interface thermocouples and other engine monitoring sensors, which was connected to an Electronic Flight Instrument System (EFIS); and a MGL XL (non-Stratomaster model) EFIS. These units were sent to the National Transportation Safety Board Recorders Laboratory for download of non-volatile memory. The last data log retrieved from the Adventure Pilot iFly 720 had a timestamp from October 21, 2017, about 2.5 months before the accident flight. The MGL RDAC XB and MGL XL units did not record data.
The engine, a Jabiru model 2200 (serial number 22A3748), was removed and shipped to Arion Aircraft, Shelbyville, Tennessee, for an engine run under the supervision of an FAA inspector. The inspector stated that the engine started and ran smoothly for about 5 to 10 minutes before the test was discontinued.
Medical And Pathological Information
The Cuyahoga County Medical Examiner's Office, Cleveland, Ohio, performed an autopsy of the pilot. The medical examiner reported the cause of death as blunt impact injuries.
Toxicology testing performed by the FAA Forensic Sciences Laboratory identified Losartan in liver. Testing was negative for ethanol and carbon monoxide.
Losartan is a prescription medication used primarily for the treatment of high blood pressure. It may be used alone or in combination with other antihypertensive agents. It is not considered to be impairing.
Tests And Research
Advisory Circular (AC) 90-109A, Transition to Unfamiliar Aircraft, discusses training and risk mitigation in flying various families of airplanes.
According to a table found in Appendix 2 of the AC, the Titan Tornado II was categorized as a low-inertia and/or high-drag airplane. Appendix 4 of the AC defined low-inertia and/or high-drag airplanes as airplanes that rapidly lose energy (airspeed and/or altitude) when there is a loss or reduction of power.
In addition, Appendix 4 d. Other Hazards, states,
Hazards of low-inertia/high-drag airplanes are not limited to power management issues. While all airplanes experience an increase in stall speed with an increase in load factor, such as during turns, these airplanes may also experience significant airspeed decay with increased load factor. This, coupled with low cruise speed to stall speed margin, make these airplanes particularly susceptible to unintentional stalls.