Tuesday, November 19, 2019

Bombardier CRJ-900ER (CL-600-2D24) Regional Jet, N131EV: Incident occurred December 01, 2019 at Buffalo Niagara International Airport (KBUF), Cheektowaga, New York

Federal Aviation Administration / Flight Standards District Office; Rochester

Aircraft while taxiing to gate slid off the taxiway.

Delta Air Lines Inc

Endeavor Air

https://registry.faa.gov/N131EV

Date: 01-DEC-19
Time: 14:55:00Z
Regis#: EDV5058
Aircraft Make: BOMBARDIER
Aircraft Model: CL600 2D24
Event Type: INCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: UNKNOWN
Activity: COMMERCIAL
Flight Phase: TAXI (TXI)
Operation: 121
City: BUFFALO
State: NEW YORK

CHEEKTOWAGA, New York (WIVB) — A Delta Air Lines aircraft slid off the taxiway Sunday morning as icy conditions gripped Western New York. It happened just after 8:30 a.m.

A Delta Air Lines flight from LaGuardia with 68 passengers and four crew members on board landed safely but as it was taxied to the gate, icy conditions caused it to slide onto the airfield’s grass.

There were no injuries, according to Niagara Frontier Transportation Authority officials.

Story and video ➤ https://www.wivb.com

CHEEKTOWAGA, New York (WKBW) — According to the Niagara Frontier Transportation Authority a Delta Air Lines aircraft slid off the taxiway upon arrival at the Buffalo Niagara International Airport Sunday morning.

Officials say around 8:30 a.m. the aircraft landed with good braking conditions on the runway but then encountered conditions on the taxiway that caused it to slide off into the grass.

The aircraft's wheel was stuck for a period of time.

There were 68 passengers and four crew members on board, no injuries were reported.

The flight arrived in Buffalo from LaGuardia Airport in New York.

Original article can be found here ➤ https://www.wkbw.com

Aerodynamic Stall / Spin: Cessna 208B Grand Caravan, TI-BEI; fatal accident occurred December 31, 2017 near Islita Airport (MRIA), Corozalito, Costa Rica

Amanda Rae Geissler, age 33

Zachary Justin Steinberg, age 19
Bruce Michael Steinberg, age 50
Irene Ginsberg Steinberg, age 51
William Aaron Steinberg, age 18
Matthew Benjamin Steinberg, age 13

Hannah Mae Weiss, age 19
Dr. Leslie Levin Weiss, age 50
Dr. Mitchell Weiss, age 52
Ari Moses Weiss, age 16

Juan Manuel Retana Chinchilla, age 52
Emma Ramos Calderón, age 26



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

Additional Participating Entities:
Federal Aviation Administration; Washington, District of Columbia
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

Location: Punta Islita, Costa Rica
Accident Number: CEN18FA063
Date & Time: 12/31/2017, 1156 CST
Registration: TI-BEI
Aircraft: CESSNA 208
Aircraft Damage: Destroyed
Defining Event: Aerodynamic stall/spin
Injuries: 12 Fatal
Flight Conducted Under: Non-U.S., Commercial

On December 31, 2017, about 1156 central standard time, a Cessna 208B airplane, Costa Rican registration TI-BEI, crashed while maneuvering after takeoff from runway 3 at Islita Airport (MRIA), near Corozalito, Costa Rica. The 2 flight crewmembers and 10 passengers were fatally injured. The airplane was destroyed by impact forces and post-impact explosion and fire. The airplane was registered to and operated by Nature Air, San José, Costa Rica, as a commercial charter flight operating under Costa Rican flight regulations. Visual meteorological conditions prevailed for the flight, which was originating at the time of the accident with an intended destination of Juan Santamaría International Airport (MROC), San Jose, Costa Rica.

The accident airplane was the second of a flight of two Cessna 208B airplanes transporting hotel guests from MRIA to MROC, where most of the passengers had connecting international airline flights. The first airplane departed MRIA using runway 3 and, after liftoff, made a right turn to the east through a pass in the hills and continued to MROC. The accident airplane took off about 15 minutes after the first airplane. According to the hotel employee who transported the passengers to the airport and was at the airport during the departures, the accident airplane did not make the same right turn as the previous airplane but instead continued on the runway heading. A ground-based video surveillance system installed at the airport captured a portion of the accident airplane's takeoff and the accident sequence. The airplane appeared within frame for about 25 seconds before the impact and could be seen climbing north on an approximate runway heading then starting a left turn. During the turn, the airplane's bank angle steepened, and the airplane descended into terrain.

The airplane's flightpath followed a valley with rising terrain on either side; the valley turned left and continued rising until reaching a mountain. When heading in a northerly direction from the airport, there was no exit from the valley. The airplane impacted terrain on the northwest side of the valley about 0.4 statute miles (sm) from the departure end of runway 3.

Pilot Information

Certificate: Commercial
Age: 52, 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: Yes
Instructor Rating(s): Airplane Multi-engine; Airplane Single-engine
Toxicology Performed: No
Medical Certification: Class 1 Without Waivers/Limitations
Last FAA Medical Exam: 11/08/2017
Occupational Pilot: Yes
Last Flight Review or Equivalent:
Flight Time:  14508 hours (Total, all aircraft), 11587 hours (Total, this make and model) 

Co-Pilot Information

Certificate: Commercial
Age: 26, Female
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 1 Without Waivers/Limitations
Last FAA Medical Exam: 06/27/2017
Occupational Pilot: Yes
Last Flight Review or Equivalent: 
Flight Time:  453 hours (Total, all aircraft) 

Captain

The 52-year-old captain held a Costa Rican commercial pilot airplane certificate with single-engine land, multiengine land, instrument, and flight instructor ratings. He also held an airline transport pilot certificate with an airplane multiengine land rating issued by the US Federal Aviation Administration (FAA). He was issued US and Costa Rican first-class airman medical certificates on November 8, 2017, with no limitations.

The pilot's resume indicated that he held captain and first officer positions for various operators from 1998 through 2017. From July 1998 to October 2005, he was employed as a pilot flying Cessna 208B airplanes for another operator (SANSA). He was then employed by Nature Air in 2006 in both captain and first officer positions in DHC-6-300 (Twin Otter) airplanes. From January 2007 to July 2017 he returned to SANSA. The captain's resume also listed employment as an instructor pilot for Cessna 208B simulators from April 2007 to July 2017, and as the training manager at SANSA from October 2011 to July 2013. His resume and logbook excerpts indicated that he had 14,508 hours total flight experience, including 11,587 hours in Cessna 208B airplanes. Training documents showed that the pilot began ground training in October 2017 at Nature Air, although no documents provided specifically listed his rehire date.

The Nature Air General Operations Manual (GOM) listed, in addition to specified ground training, that a captain or pilot-in-command have a minimum of 500 hours total flight experience, an instrument rating, and receive airplane-specific ground training, receive 8 hours of simulator and/or airplane flight instruction, pass a captain qualification, and successfully complete initial operating environment training (IOE). Limited documentation of the pilot's training was provided during the investigation. The training documents confirmed that the captain had received ground training starting in October 2017, but there were no records showing completion of required flight training or of any check flights or IOE.

First Officer

The 26-year-old first officer held a Costa Rican commercial pilot airplane certificate with single-engine land, multiengine land, and instrument ratings. She was issued a Costa Rican first-class airman medical certificate on June 27, 2017, with no limitations.

Flight logbooks were not available for the first officer; however, her resume indicated that she had accumulated 453 hours total flight experience, including 370 hours in single-engine airplanes and 83 hours in multiengine airplanes. Although her resume was not dated, it listed her position as first officer on Cessna 208B airplanes for Nature Air beginning in November 2017. Training documents indicated that she received ground training at Nature Air in October 2017.

The GOM indicated that first officers must hold a commercial pilot certificate with an instrument rating and have completed ground training in basic indoctrination, aircraft systems, human factors/crew resource management (CRM), and emergency and safety equipment. Training documents received during the investigation indicated that the first officer had received the specified training. 

Aircraft and Owner/Operator Information

Aircraft Make: CESSNA
Registration: TI-BEI
Model/Series: 208 B
Aircraft Category: Airplane
Year of Manufacture: 2001
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 208B0900
Landing Gear Type: Tricycle
Seats: 14
Date/Type of Last Inspection: 12/30/2017, Continuous Airworthiness
Certified Max Gross Wt.: 8750 lbs
Time Since Last Inspection:
Engines: 1 Turbo Prop
Airframe Total Time: 12073 Hours as of last inspection
Engine Manufacturer: Pratt & Whitney
ELT:
Engine Model/Series: PT6A-114A
Registered Owner: Nature Air
Rated Power: 675 hp
Operator: Nature Air
Operating Certificate(s) Held: None

Figure 1 - Photograph of the accident airplane.


The accident airplane was a Cessna 208B Caravan, serial number 208B0900 (Figure 1). It was a high-wing, single-turboprop-powered airplane with a fixed, tricycle landing gear configuration. The accident airplane was configured to seat 12 passengers in addition to the 2 flight crewmember seats. The airplane was powered by a 675-horsepower Pratt & Whitney Canada PT6A-114A turboprop engine, serial number PC1545, which drove a constant speed, full-feathering, reversible pitch propeller.

The airplane was originally issued an FAA experimental category airworthiness certificate on June 26, 2001 for research and development and regulatory compliance purposes. A normal category FAA airworthiness certificate was issued on September 20, 2001. An export application, dated November 11, 2011, indicated that the accident airplane was exported from the United States to Costa Rica; Nature Air was the listed purchaser. FAA records further showed that a normal category FAA airworthiness certificate was issued on June 14, 2016, indicating that the accident airplane was returned to the United States. Another export application, dated November 2, 2017, indicated that the accident airplane was again exported from the United States to Costa Rica with Nature Air as the listed purchaser.

Nature Air flight and maintenance records indicated that the airframe had accumulated 12,072.9 hours total time in service and 20,813 cycles as of the most recent entry, dated December 30, 2017.

The airplane's engine was manufactured on June 23, 2008. According to maintenance records, the engine was initially installed on another Cessna 208B before installation into the accident airplane on October 24, 2017, at an airframe time of 11,906.80 hours and 20,508 airframe cycles. At the time of installation, the engine had accumulated 3,105.4 hours total time in service and 4,332 cycles. Maintenance records indicated that the engine underwent a hot section inspection at the time of its installation into the accident airplane. Based on the aircraft records, the engine had accumulated 3,271.5 hours total time in service and 4,637 cycles since new at the time of the accident.

The airplane was maintained in accordance with an Approved Aircraft Inspection Program (AAIP).

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: , 128 ft msl
Distance from Accident Site: 25 Nautical Miles
Observation Time: 1200 CST
Direction from Accident Site: 90°
Lowest Cloud Condition:  
Visibility: 
Lowest Ceiling:
Visibility (RVR):
Wind Speed/Gusts: 4 knots / 12 knots
Turbulence Type Forecast/Actual:
Wind Direction: 90°
Turbulence Severity Forecast/Actual: 
Altimeter Setting:
Temperature/Dew Point: 32°C / 22°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Punta Islita, FN (MRIA)
Type of Flight Plan Filed:
Destination: San Jose, FN (MROC)
Type of Clearance: None
Departure Time: 1800 UTC
Type of Airspace: 

The nearest Instituto Meteorógico Nacional (IMN) weather reporting station was located about 25 miles east of the accident site at an elevation of 128 ft mean sea level (msl). At 1200, the recorded weather parameters included temperature 32°C, relative humidity 55%, and east wind at 4 knots gusting to 12 knots.

Wind models at 10 meters above ground level indicated that, for the time of the accident, the wind was about 5 knots from the northeast.

A review of a surveillance video from MRIA that captured the accident sequence did not yield enough information to determine surface wind direction. The witness at the airport at the time of the accident estimated that the wind magnitude at MRIA during the time of the accident was likely between 10 and 15 knots.

MRIA was equipped with two structures, one at each end of the airstrip's runway pavement, to accommodate windsocks; at the time of the accident, neither structure was equipped with a windsock. 

Airport Information

Airport: Islita Airport (MRIA)
Runway Surface Type: Asphalt
Airport Elevation: 65 ft
Runway Surface Condition: Dry
Runway Used: 3
IFR Approach: None
Runway Length/Width: 3000 ft / 30 ft
VFR Approach/Landing: None

Islita Airport was a privately owned, nontower-controlled airport located near the town of Corozalito, Costa Rica.

The airport had a single paved runway, runway 3/21, that was about 3,000 ft long and 30 ft wide (Figure 2). The runway pavement was cracked and had vegetation growing through the cracks at the south end. There was a hut located at the northeast end of the runway adjacent to a taxiway turnaround. Other than the turnaround at the north end, there were no other taxiways, requiring airplanes to use the runway for taxi operations. The runway was in a valley with rising terrain on all sides except to the south, which led to the Pacific Ocean. The witness who saw the accident reported that he spoke with the pilots of both airplanes before the flights departed and that the pilots acknowledged the need to use the eastern pass in order to clear terrain when departing from runway 3.

The Nature Air GOM stated that pilots would receive additional, airport-specific training before operating to or from airports with special characteristics; however, the operator provided no listing of such airports.

Figure 2 - View from runway looking north toward the mountains.


Wreckage and Impact Information

Crew Injuries: 2 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 10 Fatal
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: On-Ground
Total Injuries: 12 Fatal
Latitude, Longitude: 9.865278, -85.366111 

The airplane wreckage was removed from the accident site before NTSB arrival. The accident site was located on a heavily wooded hillside about 0.4 sm northeast (024°) of the departure end of runway 3 at an elevation of 238 ft msl. Several trees and limbs scattered about the accident site, ranging in diameter from a few inches to about 6 inches, displayed relatively clean diagonal cuts consistent with propeller contact. Based on the limited damage to surrounding tree canopy, the airplane impacted the slope in a near-vertical attitude. There was evidence of a postcrash fire (Figure 3).

The wreckage was examined after it had been moved to a hangar. The airplane was severely fragmented and burned. The cockpit section exhibited extensive impact and fire damage and no flight or engine instruments were identified during the examination. The airframe systems could not be examined due to the extensive fire and impact damage. Due to the condition of the wreckage, flight control cable continuity could not be confirmed; however, the flight control cables remained connected to the empennage surfaces and all examined control cable separations were consistent with tensile overload or cutting for removal from the accident site.

Figure 3 - View of the airplane's tail section at the accident site.


Examination of the engine revealed that the propeller and the front portion of the engine's reduction gearbox was separated from the remainder of the engine. Several components of the engine, including the accessory gearbox, were consumed by the post-impact fire. The engine's rotating shafts were not capable of rotation before engine disassembly and various components required extensive cutting to enable access to the internal engine components. The first stage compressor blades and vanes were intact with evidence of rubbing contact between the shroud and blade tips, consistent with rotation at impact. Rubbing damage was noted on the compressor turbine blades and the blade disk. Heavy impact and rubbing damage were noted on the downstream side of the power turbine guide vane. All power turbine blades were fractured, and several blade fragments were recovered within the engine exhaust. The recovered tips exhibited rubbing and many of the blades exhibited bending in the direction opposite of rotation. Additional details of the engine examination are included in the public docket. 

Medical And Pathological Information

Complete autopsy reports were not made available for review; however, the summary findings listed traumatic injuries as the cause of death for all occupants.

No medical information about the first officer was received other than the copy of her Costa Rican medical certificate.

A limited set of medical information about the pilot was reviewed and included a single page reviewing a portion of information regarding three visits for psychiatric evaluation in November and December 2011, the pilot had been diagnosed with Type I bipolar disease, attention deficit disorder with memory problems, superior intelligence, normal thyroid function, and treatment was begun with Seroquel (quetiapine, a sedating antipsychotic and antidepressant). However, there is only one page of information describing events in the pilot's childhood and young adult life. No intelligence testing or thyroid testing results are given. No testing for attention deficit disorder or symptom checklist are present. Other than a bill for further visits to the same hospital, there was no information about diagnosis confirmation or treatment effectiveness. No further information was available on the pilot's more recent medical or psychiatric conditions or treatments.

According to the FAA (US) blue ribbon medical file, the 52 year old male pilot had reported 14,532 hours of civilian flight experience during his most recent US aviation medical exam, dated 11/7/2017. He reported no visits to health care providers, no use of medications and no chronic conditions to his aviation medical examiner. No significant abnormalities were identified during the exam and the pilot was issued a first class medical certificate without limitations. His first US aviation medical certificate was issued in 1997; throughout all the ensuing years, the pilot reported no visits to healthcare providers, no use of medications, and no medical conditions. He intermittently received certificates limited by a requirement for corrective lenses; often, on the next visit the limitation was not present.

According to the Costa Rican aviation medical records, the 52 year old male pilot generally reported no medical conditions, no visits to any health care providers, and no use of medications. Over the most recent several years, the same aviation medical examiner (AME) performed both the US and Costa Rican exams. In May 2014, during a routine evaluation, the pilot reported using Lexapro (escitalopram, an antidepressant). The AME made no particular note of the finding and did not describe the pilot's mental state or reason for using the medication; he was issued a medical certificate without limitations. On the later exams, the pilot did not report the use of any medications.

Tests And Research

Surveillance Video

Evaluation of the surveillance video was performed using a computer program to estimate the airplane's location, orientation, and speed. About 13.4 seconds of the video was suitable for the estimation. The airplane's groundspeed was estimated to be 68±3 kts shortly after takeoff and the airplane was climbing about 715 ft/minute. Several seconds later, the airplane was descending about 1,510 ft/minute and its groundspeed was 82±4 kts. Its bank angle reached up to 75º right-wing-up at that time; the airplane impacted the ground shortly thereafter. The Pilot's Operating Handbook (POH) for the airplane listed a gross weight stall speed at 60° bank with 0° and 20° flap settings as 110 kts calibrated airspeed (kcas) and 98 kcas, respectively.

Weight and Balance

Fueling services were not available at MRIA and the fuel load of the airplane before takeoff could not be determined; however, fuel consumption information for the airplane indicated that a minimum of 500 lbs of fuel was required to complete the 70-nautical-mile flight. Weight and balance calculations determined that fuel load weights above 930 lbs would have resulted in exceedance of the airplane manufacturer's aft center of gravity limitation. In order to remain within the specified limits and have adequate fuel for the flight, the takeoff weight range was determined to be between 7,740 lbs (500-lb fuel load), and 8,594 lbs (930-lb fuel load).

Takeoff Performance

According to the POH, takeoffs are limited to 10 kts of tailwind; a 10-kt tailwind would result in a 50% increase in takeoff distance. Using POH data, the takeoff ground roll distance required at gross weight, 30°C air temperature, and with a 10-kt tailwind would be about 2,235 ft.

Climb Performance

The airplane's climb gradient would have been dependent on several factors, including the takeoff weight of the airplane and the flap setting used by the flight crew. Based on the range of airplane weights previously calculated and flap settings of 0° and 20°, the airplane's maximum climb gradient would have been between 495 ft/sm and 583 ft/sm.

Three different takeoff scenarios were examined to determine if the airplane had sufficient climb performance to clear the terrain surrounding the airport. The first scenario (Figure 4) examined a takeoff using the approximate ground path used by the previous airplane. The calculations showed that the airplane would have had sufficient climb performance along this route, with a minimum climb gradient margin of 40% using 0° flap at the maximum allowable weight, and a 65% margin using 20° flap and the minimum fuel weight. A positive margin indicates that the calculated climb performance exceeded the minimum needed to clear terrain. A 0% margin indicates that the airplane would have cleared terrain with no excess altitude gained. A negative margin indicates that the calculated climb performance was not sufficient to clear the terrain.

Figure 4 – Departure scenario 1 depicting the ground path of the previous airplane and the possible climb performance of the accident airplane overlaid on an elevation profile of the path.


The second scenario was a straight-out departure maintaining runway heading. Calculations showed that the airplane may not have had sufficient climb performance to clear the mountains using this route. The climb gradient margin at the maximum allowable weight and 0° flap setting was -14%, and at the minimum fuel weight using 20° flap setting was 1%.


Figure 5 - Departure scenario 2 showing a takeoff path using a straight-out departure from runway 3, and the possible climb performance of the accident airplane overlaid on an elevation profile of the path.


The final scenario was a path that turned left after takeoff, following the valley floor (Figure 6). Calculations showed that the airplane may not have had sufficient climb gradient performance to clear the mountains using this path. The climb gradient margin at the maximum allowable weight and 0° flap setting was -8%, and at the minimum fuel weight using 20° flap setting was 9%.

Figure 6 – Departure scenario 3 showing a takeoff from runway 3 over the valley floor to the north of the airport, and the possible climb performance of the accident airplane overlaid on an elevation profile of the path. 


Additional Information

A friend of one of the passengers reported that he had received a text message from the passenger before the flight indicating that the airplane had been involved in a bird strike during its arrival to MRIA. The passenger's friend provided the text messages along with the pictures showing the damage to the airplane. The photographs showed that wing's left leading edge had incurred localized damage near the landing light. The landing light lens was cracked, and the leading edge appeared to display some deformation adjacent to the landing light. The damaged area was located ahead of the landing flaps and inboard of the aileron. Due to the localized extent of the damage, the flight characteristics and controllability of the airplane would not have been adversely affected.

The witness reported that the flight crew was aware of the damage and that the captain had contacted the operator's maintenance facility to discuss the damage. He stated that the captain waited for a release from maintenance before proceeding with the flight and that this was the reason the accident airplane left about 15 minutes after the first airplane.


Figure 7 - Photograph showing the bird strike damage to the leading edge of the left wing.


The accident investigation was initially under the jurisdiction of the Costa Rican government. On May 18, 2018, the Chief of the Costa Rican Unidad de Investigación de Accidentes e Incidentes, Consejo Técnico de Aviación Civil, requested delegation of the accident investigation to the NTSB, which the NTSB accepted on May 30, 2018.














Judicial Investigation Organization (OIJ) officials collect information on January 1st, 2019, using a drone near the aircraft crash site.


The Criminal Court of Nicoya dismissed the case opened after the plane crash near the Punta Islita airport, in Nandayure, Guanacaste, in December 2017, killing 12 people: 10 American tourists and the two Costa Rican crew members.

“The Prosecutor’s Office of Nicoya confirmed that, after the plane crash, on December 31, 2017, the investigation 17-001671-0069-PE was opened; however, the dismissal was requested,” the Public Ministry informed through its press office.

“It was not possible to assess whether or not there was any human error. In the same way, it is not known if there was a mechanical failure,” said the Prosecutor’s Office.

They also clarified that although at the criminal level the case could not be continued, the process can continue with the case at the civil level.

La Nacion reports that for the moment it is unknown if the families of the victims (passengers) will take the case the civil route to make an economic claim, since the publication could not locate any relatives of the deceased, despite making multiple calls.

On December 31, 2017, a  Cessna 208B Grand Caravan plane operated by Nature Air, left the Punta Islita airfield headed for the Juan Santamaría International Airport in San Jose.

A few minutes after takeoff, at 12:10 pm, the aircraft crashed in a mountainous area. The cause is unknown until now since the General Directorate of Civil Aviation is still working on the report that it will deliver to the Technical Council of Civil Aviation (Cetac).

The victims of the accident were the pilots Juan Manuel Retana Chinchilla (52 years) and Emma Ramos Calderón (26), both Costa Ricans and members of two American families, tourists visiting Costa Rica: Leslie (50), Michell (52), Ari Moses (16) and Hannah Mae Weiss (19); and, Bruce (50), Irene (51), William (18), Zachary (19) and Matthew Steinberg (13).

Original article can be found here ➤ https://qcostarica.com

Controlled Flight Into Terrain: Cessna R182 Skylane RG, N3167C; fatal accident occurred March 28, 2018 in Ashville, St. Clair County, Alabama

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

Additional Participating Entities: 

Federal Aviation Administration / Flight Standards District Office; Birmingham, Alabama
Lycoming; Williamsport, Pennsylvania
Textron Aviation; Wichita, Oklahoma

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/N3167C 


Location: Ashville, AL
Accident Number: ERA18FA118
Date & Time: 03/28/2018, 1223 CDT
Registration: N3167C
Aircraft: CESSNA R182
Aircraft Damage:Destroyed
Defining Event: Controlled flight into terr/obj (CFIT)
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

HISTORY OF FLIGHT

On March 28, 2018, about 1223 central daylight time, a Cessna R182, N3167C, was destroyed when it impacted terrain near Ashville, Alabama, shortly after takeoff from Northeast Alabama Regional Airport (GAD), Gadsden, Alabama. The private pilot was fatally injured. The airplane was privately owned and was being operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed and no flight plan was filed for the flight, which was destined for Louis Armstrong New Orleans International Airport (MSY), New Orleans, Louisiana.

According to a review of air traffic control transcripts obtained from the Federal Aviation Administration (FAA), the pilot contacted Birmingham-Shuttlesworth International Airport (BHM), Birmingham, Alabama, shortly after departure. The pilot reported that he was 7 miles south of GAD and climbing through 700 ft to 2,500 ft and requested flight following. The airport tower controller gave the pilot a transponder code and the pilot advised the code was "in the box." There were no further communications with the pilot.

The pilot was reported missing by family members when he did not arrive at MSY. An alert notice was issued and the Air Force Rescue Coordination Center alerted the Civil Air Patrol (CAP) to the missing airplane. The CAP began a ground and air search on March 29, which was limited due to poor weather conditions. On March 30, about 1815, a CAP airplane spotted the wreckage and guided ground crews to the location.


Brett James Leistyna, 52, of Los Angeles.

PERSONNEL INFORMATION

The pilot held a private pilot certificate with an airplane single-engine land rating. His most recent FAA third-class airman medical certificate was issued on May 30, 2017, with the limitation, "Must have available glasses for near vision. Not valid for night flying or by color signal control." At that time, he reported 425 total hours of flight experience. A review of the pilot's logbooks revealed that he had accumulated about 638 total hours of flight experience.

A coworker of the pilot stated that he and the pilot worked the night before the accident from 2130 to 0230, then went back to the hotel. They met the next morning, the day of the accident, at 0700. He stated he did not sleep much the night before and believed the pilot slept even less because he had been up working after they returned to the hotel.

AIRCRAFT INFORMATION

The four-seat, high-wing, retractable-gear airplane was manufactured in 1978. It was powered by a Lycoming O-540, 235-horsepower engine. According to airplane maintenance records, an annual inspection was completed on September 19, 2017, at 2699.4 total aircraft hours.

METEOROLOGICAL INFORMATION

At 1156, the weather conditions reported at GAD included wind from 210° at 11 knots, gusting to 17 knots; 10 statute miles visibility; few clouds at 4,000 ft; temperature 24°C, dew point 16°C; and an altimeter setting of 30.09 inches of mercury.

AIRPORT INFORMATION

The field elevation at GAD was 569.2 ft mean sea level (msl), the minimum safe altitude in the area was 2,200 ft msl.

WRECKAGE AND IMPACT INFORMATION

The initial tree impact occurred on flat, heavily-wooded terrain at an elevation of about 525 ft. The trees were about 50 ft tall. About 15 ft beyond the initial tree impact was an additional tree strike, with a portion of a wing strut in the top branches. A portion of the right elevator was located in an adjacent tree about 40 ft high. The wreckage path was about 200 ft long; the main wreckage came to rest on a heading of 210°. The main wreckage was about 140 ft from the initial tree strike and comprised the cockpit, portions of the fuselage, wings, and empennage. All flight control surfaces were located at the accident site. Sections from the top and bottom of the fuselage, cockpit instruments, and the cockpit panel were located along the debris path. The rudder control cables were connected in the cockpit and empennage. The aileron cables were separated from the cockpit controls; the aileron bellcranks were not located.

The propeller was separated from the engine and located about 20 ft beyond the main wreckage; two of the three blades remained attached to the propeller hub and the hub remained attached to the propeller flange. The separated blade was found adjacent to the main wreckage. All three of the propeller blades exhibited leading edge gouging and trailing edge S-bending. The engine was separated from the airframe and located farthest from the initial tree strike. In addition, several pieces of the impacted tree exhibited 45° angular cuts consistent with propeller contact.

The left main landing gear remained attached to the fuselage and was in the extended position. The nose and right main landing gear were separated.

The cockpit instruments were heavily damaged. The dual magneto remained attached to the engine and was impact damaged. Water and mud were present when the magneto was removed from the engine, and no spark was produced when it was rotated by hand. The spark plugs from cylinder Nos. 1, 3, and 5 appeared normal. The upper spark plugs from cylinder Nos. 2 and 4 were soaked with oil and covered with dirt and the No. 6 upper spark plug was dark gray. The lower spark plugs from cylinder Nos. 2, 4, and 6 were not removed.

The engine was rotated by hand 350°. Cylinder Nos. 1, 3, and 5 were removed and continuity of the crankshaft and camshaft were confirmed by visual examination. No damage was noted to the valves pistons or connecting rods. The oil suction screen and the oil filter were absent of debris. The oil cooler was impact damaged.

The fuel selector handle was separated from the fuel selector valve. The carburetor was fractured and separated from the engine; disassembly revealed no damage to the float. The induction air box was crushed and the position of the carburetor heat selector was undetermined. The engine-driven fuel pump remained attached to the engine and no damage was noted.

The starter was impact-damaged and partially separated from the engine. The vacuum pump remained partially attached to the engine; the composite drive assembly and the carbon vanes were intact and the carbon rotor was fractured.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy of the pilot was performed by the Alabama Department of Forensic Sciences Medical Examiner's Office, Huntsville, Alabama. The cause of death was blunt force injuries.

Toxicology testing performed at the FAA Forensic Sciences Laboratory identified 11 mg/dL of ethanol in the liver but not in the muscle, which was consistent with postmortem production. Testing also identified 0.0458 µg/ml 11-hydroxy-delta-9-tetrahydrocannabinol (11-OH-THC), marijuana's primary active metabolite, in the liver and 0.0079 µg/ml in the lung. In addition, 0.907 µg/ml 11-nor-9-carboxy-delta-9-tetrahydrocannabinol (THC-COOH), marijuana's primary inactive metabolite, was detected in the liver and 0.0832 µg/ml in the lung; 0.0064 µg/ml delta-9-tetrahydrocannabinol (Delta 9-THC), marijuana's primary impairing psychoactive drug, was detected in the liver and 0.0458 µg/ml in the lung.

Blood was not available for toxicology testing. 

Pilot Information

Certificate: Private
Age: 52, 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: Yes
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 05/30/2017
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time:  638 hours (Total, all aircraft), 547.9 hours (Pilot In Command, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: CESSNA
Registration: N3167C
Model/Series: R182 NO SERIES
Aircraft Category: Airplane
Year of Manufacture: 1978
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: R18200247
Landing Gear Type: Retractable - Tricycle
Seats: 4
Date/Type of Last Inspection: 09/19/2017, Annual
Certified Max Gross Wt.:
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 2699.4 Hours as of last inspection
Engine Manufacturer: Lycoming
ELT: Installed, not activated
Engine Model/Series: O-540
Registered Owner: MONTANA GROUP LLC
Rated Power: 235 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: GAD, 569 ft msl
Distance from Accident Site: 6 Nautical Miles
Observation Time: 1156 CDT
Direction from Accident Site: 42°
Lowest Cloud Condition: Few / 4000 ft agl
Visibility:  10 Miles
Lowest Ceiling:
Visibility (RVR):
Wind Speed/Gusts: 11 knots / 17 knots
Turbulence Type Forecast/Actual:
Wind Direction: 210°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 30.09 inches Hg
Temperature/Dew Point: 24°C / 16°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: GADSDEN, AL (GAD)
Type of Flight Plan Filed: None
Destination: NEW ORLEANS, LA (MSY)
Type of Clearance: VFR Flight Following
Departure Time:
Type of Airspace: Class G

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: 33.895556, -86.161389

System / Component Malfunction / Failure (Non-Power): Aeronca 15AC Sedan, N1337H; accident occurred December 23, 2016 at Oakland County International Airport (KPTK), Waterford Township, Michigan

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

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; East Michigan; Belleville, Michigan

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/N1337H

Location: Pontiac, MI
Accident Number: CEN17LA070
Date & Time: 12/23/2016, 1618 EST
Registration: N1337H
Aircraft: AERONCA 15AC
Aircraft Damage: Substantial
Defining Event: Sys/Comp malf/fail (non-power)
Injuries: 1 None
Flight Conducted Under: Part 91: General Aviation - Personal

On December 23, 2016, about 1618 eastern standard time, an Aeronca model 15AC airplane, N1337H, collided with a snowbank and nosed over while landing at Oakland County International Airport (PTK), Pontiac, Michigan. The private pilot was not injured, and the airplane sustained substantial damage. The airplane was registered to Samcran LLC and operated under the provisions of Title 14 Code of Federal Regulations Part 91 without a flight plan. Day visual meteorological conditions prevailed for the local flight that departed PTK about 1500.

The pilot reported that the purpose of the flight was to practice landings in the tailwheel-equipped airplane. After departure, he remained in the airport traffic pattern and completed 14 uneventful touch-and-go landings before deciding to conclude the flight with a full stop landing on runway 27R. He reported that he made an uneventful full stall (three point) landing on the runway centerline. However, shortly after touchdown, the airplane suddenly swerved to the left. He attempted to regain directional control with an application of right rudder and increased engine power for an aborted landing. The airplane then swerved to the right as he simultaneously applied forward stick pressure to get the tail airborne. The airplane continued to swerve right until it collided with a 3 ft high snowbank located alongside the runway. The airplane then nosed over and came to rest in the snow-covered area located off the right side of the runway. The pilot was able to exit the airplane uninjured after releasing his lap belt.

The pilot had accumulated 205 hours in the airplane since he purchased it in May 2015. The pilot noted that most of his flight experience in the airplane, 172.9 hours, had been flown with the airplane equipped with landing floats instead of a conventional (tailwheel) landing gear. He had logged 32.1 hours of tailwheel time, all of which were flown in the accident airplane. The pilot received his tailwheel endorsement on March 11, 2016.

A postaccident examination by a Federal Aviation Administration (FAA) airworthiness inspector revealed substantial damage to both main wing spars and the rudder. The FAA inspector reported that the four 0.25 inch anchor bolts used to attach the left brake torque plate to its respective landing gear axle endplate had sheared. The unrestrained torque plate allowed the brake assembly to rotate with the brake disk that was attached to the wheel. With the forward rotation, the brake line was pulled around the gear leg until the 90° aluminum fitting that connected the brake line to the caliper assembly sheared. The tire inner sidewall exhibited a gash that partially exposed the inner tube. The inner tube did not rupture but was partially protruding from the gash in the tire sidewall. The sheared anchor bolts had worn a grove on the inboard surface of the left brake disk.

According to maintenance documentation, on January 27, 2016, the airplane had been modified through the implementation of STC No. SA1114NW with Cleveland 8.00 x 6.00 main wheels, tires, and 6 inch external, single cylinder, dual piston brake assemblies. The landing floats were reinstalled on an unknown date during 2016. On December 17, 2016, the landing floats were removed, and the main landing gear and wheels were reinstalled to convert the airplane back into a conventional gear land airplane. The accident occurred during the second flight after the airplane was reequipped with the conventional landing gear.

The installation instructions for STC No. SA1114NW specified that the stock Cleveland brake torque plates be modified per the accompanying installation drawing No. 1200-4 and to use 0.375 inch outside diameter (OD) to 0.25 inch inside diameter (ID) bushings. Installation drawing No. 1200-4 specified that each torque plate required two 0.25 inch holes to be marked and drilled to ensure proper alignment with their respective landing gear axle endplate. Each torque plate was then attached to its respective landing gear axle endplate with four 0.25 inch anchor bolts and washers. The two 0.25 inch holes drilled in each torque plate did not require bushings when installed with a 0.25 inch anchor bolt; however, the remaining two 0.375 inch holes used to attach each torque plate required 0.375 inch OD to 0.25 inch ID bushings to properly support the 0.25 inch anchor bolts.

Further examination of the airplane revealed that both torque plates were not modified and installed in accordance with the STC No. SA1114NW installation instructions. Specifically, the supplied brake torque plates were not modified with the two additional 0.25 inch holes to ensure proper alignment with the landing gear axle endplate. Additionally, both torque plates were installed with improperly sized bushings in multiple holes. The left torque plate, which had separated from the left landing gear axle endplate, had two bushing remaining; one bushing had the correct 0.25 inch ID, the other bushing had a larger 0.3125 inch ID. The right torque plate, which remained attached to the right landing gear axle endplate, was incorrectly installed with four 0.3125 inch ID bushings.

Pilot Information

Certificate: Private
Age: 53, Male
Airplane Rating(s): Single-engine Land; Single-engine Sea
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 With Waivers/Limitations
Last FAA Medical Exam: 10/07/2016
Occupational Pilot: No
Last Flight Review or Equivalent: 10/30/2016
Flight Time:  342 hours (Total, all aircraft), 205 hours (Total, this make and model), 253 hours (Pilot In Command, all aircraft), 49 hours (Last 90 days, all aircraft), 16 hours (Last 30 days, all aircraft), 1 hours (Last 24 hours, all aircraft) 

Aircraft and Owner/Operator Information

Aircraft Make: AERONCA
Registration: N1337H
Model/Series: 15AC
Aircraft Category: Airplane
Year of Manufacture: 1949
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 15AC-377
Landing Gear Type: Tailwheel
Seats: 2
Date/Type of Last Inspection: 04/14/2016, Annual
Certified Max Gross Wt.: 2100 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 4380 Hours as of last inspection
Engine Manufacturer: Continental
ELT: C126 installed, not activated
Engine Model/Series: C-145-2
Registered Owner: On file
Rated Power: 145 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: PTK, 981 ft msl
Distance from Accident Site: 0 Nautical Miles
Observation Time: 1553 EST
Direction from Accident Site:
Lowest Cloud Condition:
Visibility:  5 Miles
Lowest Ceiling: Broken / 8000 ft agl
Visibility (RVR): 
Wind Speed/Gusts: 6 knots /
Turbulence Type Forecast/Actual: None / None
Wind Direction: 190°
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 30.18 inches Hg
Temperature/Dew Point: 1°C / -2°C
Precipitation and Obscuration: Moderate - Haze
Departure Point: Pontiac, MI (PTK)
Type of Flight Plan Filed: None
Destination: Pontiac, MI (PTK)
Type of Clearance: VFR
Departure Time: 1500 EST
Type of Airspace: Class D

Airport Information

Airport: Oakland County International A (PTK)
Runway Surface Type: Asphalt
Airport Elevation: 981 ft
Runway Surface Condition: Dry
Runway Used: 27R
IFR Approach: None
Runway Length/Width: 5676 ft / 100 ft
VFR Approach/Landing: Full Stop; Traffic Pattern

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:  42.665556, -83.420556 (est)