Wednesday, December 25, 2019

Controlled Flight into Terrain: Piper PA-32R-300 Cherokee Lance, C-GYGY; fatal accident occurred February 22, 2018 in Monticello, San Juan County, Utah

Clint Kaupp, Bill Kaupp, Tim Mueller, and Ron Mckenzie. 


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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Salt Lake City, Utah
Lycoming Engines; Williamsport, Pennsylvania
Piper Aircraft, Wichita, Kansas
Transportation Safety Board of Canada; Edmonton, Alberta, Canada

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


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

http://wwwapps.tc.gc.ca




Location: Monticello, UT
Accident Number: WPR18FA095
Date & Time: 02/22/2018, 1056 MST
Registration: C-GYGY
Aircraft: PIPER PA32R
Aircraft Damage: Destroyed
Defining Event: Controlled flight into terr/obj (CFIT)
Injuries: 4 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal

On February 22, 2018, about 1056 mountain standard time, a Piper PA-32R-300 airplane, Canadian registry C-GYGY, was destroyed when it impacted terrain near Monticello, Utah. The private pilot and the three passengers were 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. Undetermined meteorological conditions prevailed. No flight plan was filed for the flight. The airplane departed Grand Junction Airport (GJT), Grand Junction, Colorado, about 0937 for an undetermined destination.

The pilot and passengers were all Canadian citizens and resided in the province of Alberta. According to the pilot's daughter, on a return trip from the US to Alberta in the airplane in early February, the pilot left the airplane at Cut Bank International Airport (CTB), Cut Bank, Montana, reportedly because adverse weather prevented completion of the trip. The airplane remained hangared at CTB until February 21, when the pilot and passengers drove to CTB to begin the flight journey that would include the accident leg.

The pilot's daughter reported that the pilot and passengers had planned to fly from CTB to Albuquerque, New Mexico, on February 21, to allow the pilot to examine an airplane for possible purchase. She was not aware of any planned stops. She reported that the airplane departed CTB about 1000. However, due to weather, the flight landed at GJT, and the group overnighted in the local area. According to fixed base operator personnel at GJT, the airplane arrived about 1605 on February 21. Family members of the pilot and passengers were not aware of any intermediate stops between CTB and GJT, but they would not necessarily be aware of any such stops.

The direct line distance between CTB and Albuquerque was about 853 nautical miles (nm). The direct line distance from CTB to GJT was about 592 nm, and the direct line distance from GJT to Albuquerque was about 262 nm. Albuquerque is south-southeast of GJT. (See figure 1.)

Figure 1 - Trip Cities

According to GJT air traffic control tower information, on February 22, the airplane departed on the accident flight to the northeast. No further communications between the airplane and any air traffic control or other ground facilities were located.

Review of Federal Aviation Administration (FAA) ground-based radar data revealed a track from an unidentified aircraft broadcasting on the visual flight rules transponder code of 1200 appeared to be that of the accident airplane. The first radar return was received at 1004:04 about 16 nm west-northwest of GJT, at a radar-indicated altitude of 7,900 ft. The track was oriented towards the southwest, on a course of about 237° true. The airplane remained level at 7,900 ft until about 1005, when it began a climb to 8,500 ft, and then remained at that altitude until about 1015.

About 1015 the airplane began a climb to about 10,200 ft, where it leveled off. About 1017, the track turned to a course of about 189°, and remained there for about 9 minutes. About 1026, the track turned to the south-southeast, onto a course of about 157°. About 1031, the airplane began a descent of about 150 fpm, and about the same time, the track turned to the south, to a new course of about 173°. The final radar return was received at 1033:34. That return was located about 35 mile north-northwest of the accident site, at a radar-indicated altitude of 9,200 ft.

The approximate floor of radar system coverage in the area between the final radar return and the accident site was about 9,500 ft, and underlying terrain elevations were generally about 7,000 ft. This provided the airplane with a few thousand feet of altitude in which to fly while remaining below the radar coverage floor. Calculations using a nominal airplane cruise speed of 140 knots and a southerly wind of about 20 knots indicate that the airplane would have traveled about 53 nm in the time between the final radar return and the accident. This is about 22 nm more than the straight-line distance between the final radar return and the accident site. (see Figure 2 and Figure 3)


Figure 2 - Radar Track

Figure 3 - Radar Altitude

About 2200 on February 22, in response to a concerned party, the FAA issued an Alert Notice stating that the airplane was overdue. About 0215 on February 23, the US Air Force Rescue Coordination Center (AFRCC) reported that a 121.5 MHz emergency locator transmitter signal had been detected in the vicinity of La Sal Junction, Utah. Multiple ground and airborne searches were initiated that day, and at 1649, the airplane wreckage was located by a Civil Air Patrol search aircraft. Law enforcement personnel arrived at the scene soon thereafter, and the wreckage was confirmed to be that of the missing airplane. The wreckage was examined on scene by FAA, Piper, and NTSB personnel on February 26. The wreckage was recovered on February 27 for transport to, and subsequent detailed examination at, a secure facility. 

Pilot Information

Certificate: Private
Age: 64, 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
Last FAA Medical Exam: 02/07/2018
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time: (Estimated) 597 hours (Total, all aircraft) 

The pilot held a Transport Canada (TC) private pilot license. According to a TC explanatory letter, the pilot's "license is endorsed with a blanket type rating for All Single Pilot Non-High-Performance Single Engine Land Aeroplanes." Subsequent communication from TC indicated that a high-performance airplane was defined as "an aeroplane that is specified in the minimum flight crew document as requiring only one pilot and that has a maximum speed (Vne) of 250 KIAS or greater or a stall speed (Vso) of 80 KIAS or greater." The pilot did not hold an instrument rating, and his license bore the restriction, "Valid Daylight Only," which applied in both Canada and the US.

Based on TC and FAA information, regarding the TC certificate restriction, the accident airplane was not considered "high-performance" and therefore did not apply, but the daylight restriction applied to the pilot whether he was flying in Canada or the US. Flight time records indicated that, as of February 9, 2018, the pilot had about 597 total hours of flight experience. His most recent TC Category 3 medical certificate was issued in February 2018.

The pilot's journey log was recovered in the wreckage. It had separated into a few major portions, and some pages were missing. The earliest entry was dated February 13, 1983, and the most recent was dated February 9, 2018. The first entry that cited the accident airplane was dated June 24, 2014. A review of the entries in the log indicated that the pilot had accumulated about 346 hours in the accident airplane. Due to the damage and missing pages, his total flight experience could not be determined from the recovered Journey log.



Aircraft and Owner/Operator Information

Aircraft Make: PIPER
Registration: C-GYGY
Model/Series: PA32R 300
Aircraft Category: Airplane
Year of Manufacture: 1976
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 32R7680182
Landing Gear Type: Retractable - Tricycle
Seats: 6
Date/Type of Last Inspection: 09/22/2017, Annual
Certified Max Gross Wt.:
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 2744 Hours as of last inspection
Engine Manufacturer: Lycoming
ELT: C91 installed, activated, aided in locating accident
Engine Model/Series: IO-540
Registered Owner: 1520795 Alberta Ltd
Rated Power:
Operator: On file
Operating Certificate(s) Held: None



General

TC information indicated that the airplane was manufactured in 1976 and was equipped with a Lycoming IO-540 series engine. The most recent annual or 100-hour inspection was completed in September 2017. The maintenance records indicated that, at the time of that inspection, the airplane had a total time (TT) since new of 2,743.5 hours, the propeller had a TT of 32.2 hours, and the engine time since overhaul was 762.8 hours.

The pilot was in the process of selling the airplane and an undated advertisement stated that the airplane and propeller had TT values similar to the maintenance records, but that the engine time since overhaul was cited as 682 hours. The advertisement noted that the airplane was equipped with an autopilot and an engine monitor with recording capabilities.

Fuel Capacity and Performance Information

The airplane was equipped with a total of four fuel tanks. These were configured as two fuel tanks and one filler neck per wing. The total fuel capacity was 98 gallons, of which 94 gallons were usable.

Takeoff, climb, and cruise fuel consumption vary as a function of several parameters, including airplane weight, ambient conditions, and power settings. No details regarding the route, altitude, or speed of the flight between CTB and GJT could be obtained; however, Pilot's Operating Handbook (POH) performance data indicated that the airplane would have consumed about 4 gallons during the takeoff and climb to altitude. POH cruise flight fuel burn rates ranged between 12 and 18 gallons per hour (gph), with true airspeed values in the 140 to 150 knot range. Based on these values, the approximate fuel required for a non-stop, direct trip from CTB to GJT would range between 55 and 72 gallons, with a trip duration of about 4 to 5 hours.

Fueling Information

According to FBO personnel at GJT, after the pilot landed at GJT, he requested a top-off of the fuel tanks, but he did not remain with the airplane for the refueling. The airplane was serviced at GJT with 17.6 gallons of fuel that same day. Queries to several airports between CTB and GJT did not reveal any evidence of any interim stops or fuel purchases, but those queries were not all-inclusive. Pilot and passenger family members were asked to review credit card statements for fuel purchases, but none were located.



METEOROLOGICAL INFORMATION

Pilot Briefing Information

According to Leidos Flight Service, the pilot did not contact either Leidos or DUATS on the accident day. According to a representative of ForeFlight, a pilot information and flight planning software company, no weather briefings were requested for the airplane using ForeFlight Mobile before the accident flight, or for any flights immediately preceding the accident flight. It also "appeared" that the accident pilot did not sign in to and use his device on ForeFlight Mobile to view any weather imagery before the accident flight. As of the date of the accident, the ForeFlight system did not have the ability to record whether the pilot viewed any "live" weather overlays, such as radar or satellite imagery, over the map view before the flight. The ForeFlight system also did not have the ability record whether the pilot viewed any individual METARs, TAFs or "MOS" (Model Output Statistics) forecasts.

Weather Observations

An Automated Weather Observing System (AWOS) was located at Blanding Municipal Airport (BDG), Blanding, Utah, about 19 nm southwest of the accident location at an elevation of 5,870 ft. This station did not have a precipitation discriminator and sky condition was not reported. The 1055 observation included wind from 180° at 8 knots, visibility 10 statute miles, temperature 0°C, dew point -8°C, and an altimeter setting of 30.08 inches of mercury.

An Automated Surface Observing System located at Cortez Municipal Airport (CEZ), Cortez, Colorado, about 39 miles southeast of the accident location at an elevation of about 5,920 ft, was the closest reporting official ceilometer to the accident site. The 1053 CEZ observation reported wind from 230° at 11 knots with gusts to 18 knots, visibility 10 statute miles, a broken cloud ceiling at 4,800 ft above ground level (agl), overcast clouds at 6,500 ft agl, temperature 1°C, dew point -10°C, and an altimeter setting of 30.03 inches of mercury.

There were no publicly-disseminated pilot reports made within about 40 nm and 2 hours of the accident location for altitudes below 15,000 ft.

An atmospheric sounding valid for the accident time and location indicated a surface wind from the south-southwest of about 10 knots. Above this level, the wind veered to the west-southwest and increased steadily in magnitude to about 30 knots about 15,000 ft. Between about 9,000 and 13,000 ft, the relative humidity was between 88 and 93 percent. The freezing level was below the surface. A risk of light mixed, and rime icing was identified between about 9,000 and 13,000 ft. No layers of potential significant turbulence were identified below 20,000 ft.

Satellite visible and infrared imagery near the time of the accident depicted cloudy skies over the accident region with the infrared data indicating cloud top heights about 26,600 ft. Analysis of National Weather Service (NWS) forecast and weather model data indicated that the cloud bases in the region of the accident site (elevation 6,850 ft) were likely about 9,500 to 10,000 ft msl.

The local NWS reported that it faced, "A challenging aviation forecast on Thursday [February 22] afternoon with several instances of convective snow bands producing highly variable conditions from the Colorado border eastward. These bands have been capable of dropping visibility to under a mile and lowering ceiling heights to LIFR [low IFR] levels, however only for short periods of time." 



Meteorological Information and Flight Plan

Conditions at Accident Site: Unknown
Condition of Light: Day
Observation Facility, Elevation: BDG, 5868 ft msl
Distance from Accident Site: 19 Nautical Miles
Observation Time: 1055 MST
Direction from Accident Site: 225°
Lowest Cloud Condition: Unknown
Visibility:  10 Miles
Lowest Ceiling: Unknown
Visibility (RVR):
Wind Speed/Gusts: 11 knots / 18 knots
Turbulence Type Forecast/Actual:
Wind Direction: 230°
Turbulence Severity Forecast/Actual:
Altimeter Setting:
Temperature/Dew Point:
Precipitation and Obscuration:  Unknown Obscuration; Unknown Precipitation
Departure Point: Grand Junction, CO (KGJT)
Type of Flight Plan Filed: None
Destination:
Type of Clearance: Unknown
Departure Time: 0937 MST
Type of Airspace: Unknown 

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 3 Fatal
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 4 Fatal
Latitude, Longitude: 37.781667, -109.173333 (est) 



General Information

The partially snow-covered wreckage was in a field about 10 nm southeast of Monticello, Utah, about 85 nm south-southwest of the accident leg departure airport. Investigative examination of the site was conducted 4 days after the accident. Occupant watches indicated that the time of the accident was about 1056.

The debris field was oriented on a magnetic track of about 085° (095° true) and was about 550 ft long. The site elevation was about 6,850 ft msl. The wreckage was highly fragmented. An investigative team mapped the debris field and conducted an initial wreckage examination. All major components of the airplane, including all flight control surfaces, were identified at the scene. No fuel was observed on site. No evidence of any pre-impact mechanical deficiencies that would have precluded continued flight were observed. No evidence of any pre-or postimpact fire was observed.

Airframe Information

Both wings had fracture-separated from the fuselage. The flap and aileron were fracture-separated from the left wing. The aileron, outboard fuel tank, and wing tip were fracture-separated from the right wing. The right flap remained attached to the wing.

The horizontal stabilator, with its balance weight in place, remained attached to the hinges on the aft fuselage closeout plate assembly. The pitch trim was set to about halfway between the neutral and full airplane nose-up positions. The vertical stabilizer and rudder remained attached to the fuselage only at the fin root fitting. The flight control cables were fractured into multiple sections consistent with tensile overload. The flap setting at the time of impact could not be determined. The landing gear damage was consistent with it being retracted at the time of impact.

The cabin was crushed, twisted, and fragmented. The fuel selector valve was found set to the left fuel tank position. Most flight instruments, avionics, and circuit breakers were fracture-separated from the airplane. Most cockpit control positions, instrument indications, and switch positions were deemed unreliable due to the severity of airplane damage.

Engine Information

The engine was separated from the airframe at the engine mount during the accident sequence. The engine sustained significant impact damage, which separated the propeller assembly, the exhaust system, most accessories, the fuel injection servo, and the oil filter. Mechanical continuity was established throughout the engine internal rotating group, valve train, and accessory section during manual rotation of the crankshaft. The combustion chambers, valves, and spark plug electrodes remained mechanically undamaged and there was no evidence of foreign object ingestion or detonation. The gas paths and combustion signatures displayed coloration consistent with normal operation.

Propeller Information

The propeller hub was fracture-separated from the engine. The hub was fractured into multiple fragments and all three propeller blades were liberated from the hub. All three blades incurred moderate aft bending at their 1/2- to 2/3-span locations with multiple leading-edge nicks/gouges and moderate scouring on their leading edges and tips. These signatures were consistent with power being applied to the propeller at the time of impact.

MEDICAL AND PATHOLOGICAL INFORMATION

Pilot

The Utah Department of Health Office of the Medical Examiner, Taylorsville, Utah, conducted the autopsy on the pilot. The cause of death was "multiple injuries" due to impact. Examination for pre-existing or contributing medical conditions was not possible due to the injury level. Toxicology testing by NMS Labs for the Utah medical examiner did not reveal the presence of carbon monoxide, alcohol, or any tested-for drugs, except caffeine.

Toxicology testing on pilot tissue samples was also conducted by the FAA Forensic Sciences Laboratory. No carbon monoxide or cyanide testing was performed by this laboratory. Normally, central blood is needed to establish medication levels that can be used to estimate impairment, but only pilot's muscle tissue was available. No ethanol was detected in the pilot muscle tissue. No tested-for drugs, except Diphenhydramine, were detected in the pilot's muscle tissue. The detected level was below the FAA threshold for reporting the value of the quantity detected.

Diphenhydramine (generic and several brand name products such as Benadryl®, Sominex®, Advil® PM) is an over-the-counter antihistamine used to treat allergic conditions, and is helpful as a sleep aid. This medication could impair mental and/or physical ability required for the performance of tasks such as flying, and the FAA recommends waiting at least 60 hours after the last dose before performing safety-related duties.

Passengers

Toxicology testing on samples from the three passengers was also conducted by the FAA Forensic Sciences Laboratory. Blood samples from all three individuals tested negative for carbon monoxide. 

Flight Recorders

The airplane was equipped with an Insight G2 engine monitor, which stored data on an SD memory card that the operator/pilot could insert into a slot in the front of the display instrument. The instrument was located in the wreckage, but the card slot was empty. It was not determined whether there was a card installed for the flight, and a detailed search did not locate any SD memory card in the recovered wreckage. 

Additional Information

Controlled Flight Into Terrain (CFIT)

FAA issued Advisory Circular 61-134: General Aviation Controlled Flight into Terrain Awareness defines a CFIT accident as a situation that occurs when a properly functioning aircraft "is flown under the control of a qualified pilot, into terrain (water or obstacles) with inadequate awareness on the part of the pilot of the impending collision."

Loss of Control in Flight: Robinson R44 Raven II, N7530R; fatal accident occurred January 30, 2018 near John Wayne Airport (KSNA), Orange County, California

Joseph Anthony Tena, 60, of Newport Beach, California 

 Brian Reichelt, 56, of Hollywood, Florida
Kimberly Lynne Watzman, 45, of Santa Monica, California 


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

Additional Participating Entities:

Federal Aviation Administration; Washington, District of Columbia
Lycoming Engines; Williamsport, Pennsylvania
Robinson Helicopter Company; Torrance, California 
 
Aviation Accident Factual Report - National Transportation Safety Board: https://app.ntsb.gov/pdf


Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms 
 
http://registry.faa.gov/N7530R 





Location: Newport Beach, CA
Accident Number: WPR18FA077
Date & Time: 01/30/2018, 1350 PST
Registration: N7530R
Aircraft: ROBINSON HELICOPTER R44
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight
Injuries: 3 Fatal, 1 Serious, 1 Minor
Flight Conducted Under: Part 91: General Aviation - Personal

On January 30, 2018, about 1350 Pacific standard time, a Robinson Helicopter R44, N7530R, was destroyed when it impacted houses near Newport Beach, California shortly after takeoff. The private pilot and two of the three passengers sustained fatal injuries, one passenger sustained serious injuries, and one person on the ground sustained minor injuries. The helicopter was registered to Spitzer Helicopter and was 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 originated from John Wayne-Orange County Airport (SNA), Santa Ana, California, about 1 minute before the accident, with an intended destination of Catalina Island, California.

The surviving passenger reported that the pilot and all of the passengers met at the pilot's office and planned to fly to Catalina Island for lunch. Following a brief conversation, the pilot drove the passengers to the airport. The passenger stated that, during the drive, the pilot received a phone call during which he appeared to be frustrated. The passenger asked if everything was ok, and the pilot responded everything was fine and he just wanted a different helicopter. Upon arriving at the airport, they all walked to the helicopter and the pilot appeared to conduct a preflight inspection.

The passenger recalled that the pilot never asked any of the passengers about their weights, nor did he assign them seats. After all the passengers boarded the helicopter, they put on the headsets and the pilot started the engine. The passenger stated that the helicopter started to lift up, shimmied a little, and seemed to hover momentarily before it began a gradual climb. As the helicopter continued to climb steadily, in more of a level attitude than the initial lift off, the helicopter suddenly descended straight down nose first and impacted the ground. Following transport to the hospital, the passenger reported to law enforcement that the pilot said "something's wrong" and apologized to the passengers before stating that he could probably "save it."

Surveillance video footage of the takeoff showed the helicopter slightly move forward in a nose low attitude, lift off, rotate left, increase in a nose-low attitude, and yaw to the right. As the helicopter briefly transitioned into a level attitude, it moved momentarily out of view behind a parked airplane. The tailboom of the helicopter became visible shortly after, in an elevated attitude consistent with a nose-low pitch attitude. As the rest of the helicopter became visible, it appeared to be in a slight climbing left turn, remaining in a nose-low attitude. The helicopter briefly descended and appeared to transition into a level attitude before it began a climb. The helicopter continued the climb while transitioning to a nose-low pitch attitude as it traveled out of frame.

A witness adjacent to the accident site reported observing the helicopter "going down quickly diagonally" before it "pulled [the] nose up and appeared to try an auto rotation while it continued to go down." A second witness reported that they observed the helicopter flying on an easterly heading and descending until it impacted two residential houses. The witness reported that they did not see any parts come off of the helicopter prior to the impact.

A review of archived Federal Aviation Administration (FAA) radar data revealed that the helicopter departed SNA on a southerly heading followed by a slight left turn to a southeasterly heading. The data showed that the helicopter climbed to a maximum altitude of 500 ft mean sea level (msl) and traveled along a southeasterly heading for about 13 seconds. The data showed that the helicopter then descended from 500 ft msl to the last recorded target, at 200 ft msl, in 11 seconds. The last recorded radar return was almost directly above the initial impact area. Review of recorded radio transmissions revealed that the pilot did not make any distress calls.



Pilot Information

Certificate: Private
Age: 60, Male
Airplane Rating(s): None
Seat Occupied:Right
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): Helicopter
Second Pilot Present:No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 Without Waivers/Limitations
Last FAA Medical Exam: 07/11/2016
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time: 195 hours (Total, all aircraft) 

The pilot held a private pilot certificate with a rotorcraft-helicopter rating and a third-class FAA medical certificate issued on July 11, 2016, with no limitations. The pilot reported on the application for the medical certificate 195 total hours of flight experience, of which 25 hours were in the previous 6 months. The pilot's logbooks were not located. 



Aircraft and Owner/Operator Information

Aircraft Make: ROBINSON HELICOPTER
Registration: N7530R
Model/Series: R44 UNDESIGNATED
Aircraft Category:Helicopter
Year of Manufacture: 2003
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 1295
Landing Gear Type: Emergency Float; Skid;
Seats:
Date/Type of Last Inspection: 12/07/2017, 100 Hour
Certified Max Gross Wt.: 2400 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 6966.3 Hours as of last inspection
Engine Manufacturer: LYCOMING
ELT: Installed
Engine Model/Series: O-540-F1B5
Registered Owner: SPITZER HELICOPTER LLC
Rated Power: 260 hp
Operator: On file
Operating Certificate(s) Held: None

The accident helicopter was a Robinson Helicopter R44, serial number 1295, and was powered by a 235-horsepower Lycoming O-540-F1B5 engine, serial number L-25375-40A. The most recent 100-hour inspection was completed on December 7, 2017, at a Hobbs time of 568.6 hours and an airframe total time of 6,966.3 hours. The most recent annual inspection was completed on June 1, 2017, at a Hobbs time of 383.9 hours, airframe total time of 6,781.6 hours, and engine time since major overhaul of 383.9 hours.

According to representatives from a fixed-base operator located at SNA, the helicopter was refueled with 15.8 gallons of 100 low-lead aviation fuel based on a request to top off the main fuel tank only.

Using the basic empty weight of the helicopter, fuel load, and weights of the occupants and baggage, the helicopter weighed about 2,476 lbs at the time of takeoff with a longitudinal center of gravity (CG) of 93.42 inches. The calculated weight exceeded the published maximum gross weight of 2,400 lbs and the CG was near the forward range noted in the R44 Pilot Operating Handbook.



Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KSNA, 55 ft msl
Distance from Accident Site: 1 Nautical Miles
Observation Time: 2153 UTC
Direction from Accident Site: 10°
Lowest Cloud Condition: Few / 13000 ft agl
Visibility:  10 Miles
Lowest Ceiling: Broken / 18000 ft agl
Visibility (RVR):
Wind Speed/Gusts: 5 knots /
Turbulence Type Forecast/Actual:
Wind Direction: 210°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 29.98 inches Hg
Temperature/Dew Point: 26°C / -2°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Santa Ana, CA (SNA)
Type of Flight Plan Filed: None
Destination: Catalina Island, CA
Type of Clearance: VFR
Departure Time: 1349 PST
Type of Airspace: Class C

A review of recorded data from the SNA automated weather observation station, located about 2 miles north of the accident site, revealed that the conditions at 1353 included wind from 210° at 5 knots, visibility 10 statute miles, few clouds at 13,000 ft above ground level (agl), broken cloud layer at 18,000 ft agl, temperature 26°C, dew point -2°C, and an altimeter setting of 29.98 inches of mercury. 

Airport Information

Airport: JOHN WAYNE AIRPORT-ORANGE COUNTY (SNA)
Runway Surface Type: N/A
Airport Elevation: 56 ft
Runway Surface Condition: Dry
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: Forced Landing


Tail rotor as located. 

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 2 Fatal, 1 Serious
Aircraft Fire: None
Ground Injuries: 1 Minor
Aircraft Explosion: None
Total Injuries: 3 Fatal, 1 Serious, 1 Minor
Latitude, Longitude: 33.654167, -117.871389 

The helicopter impacted multiple residential structures and a residential street about 0.95 nm miles south-southeast of the departure end of runway 20R at SNA. The initial impact point was identified by damage to the roof of a single-story home. The tail rotor gearbox and one tail rotor blade were located on top of the roof of a single-story home, partially lodged within a hole in the roof. The empennage and opposing tail rotor blade were located between the two homes, surrounded by thick vegetation. Additional impact damage was observed to a palm tree located between the homes.

Numerous impact gouges and paint transfer marks were located on the street in front of both homes, consistent with fuselage and main rotor blade impact. The helicopter came to rest on its left side against a single-story home on a heading of about 189° magnetic, about 86 ft from the first identified point of impact. Throughout the wreckage debris path, plexiglass fragments, clay roofing material, palm tree fragments, and portions of both main rotor blades were observed.

The empennage and the aft section of the tailcone were separated from the airframe. The empennage was separated from the tailcone. The tail rotor gearbox was separated from the empennage and tailcone. The skids were detached and folded underneath the wreckage. The forward section of the tailcone was bent forward almost 180°.

The forward tail rotor drive shaft flex coupling was intact. The intermediate flex coupling was distorted and detached at one arm. The tail rotor drive shaft was separated into multiple sections. The tail rotor drive shaft damper assembly was detached from the tailcone and the tail rotor drive shaft bearing. The bearing rotated freely. The friction at the damper linkage was normal. The aft flex coupling was detached at the tail rotor gearbox yoke input arms. The tail rotor gearbox rotated freely and contained oil. The slider bearing rotated freely. One of the tail rotor blades was separated and distorted. The opposing blade remained attached and exhibited leading edge damage.

The drive belts remained intact and in place within their respective grooves. The sprag clutch operated normally. The belt tension actuator was intact and when operated, the belt tension actuator extended and contracted. Both the upper and lower actuator bearings rotated freely.

The main rotor blades remained attached to the hub. Both main rotor blades were intact. One of the rotor blades was bent upward about mid-span and exhibited slight bending opposite of the direction of rotation near the blade tip. A portion of the blade honeycomb skin structure was torn away from the spar at the blade tip. The opposing main rotor blade exhibited dents and scuffs about 10 inches outboard of the hub. The blade was bent downward about 135° about 2 ft outboard of the hub. The blade was also bent upward mid-span and bent aft opposite of the direction of rotation along the outboard third of the blade. A portion of the blade honeycomb skin structure was torn away from the blade tip.

Dents observed in the oil cooler were consistent with impact from the starter ring gear. At the upper belt sheave, score marks consistent with rotational contact from adjacent components were observed.

Flight control continuity was established throughout the helicopter from the cockpit controls to the main rotor and tail rotor controls through various overload fractures.

The engine remained attached to the airframe. The upper spark plugs were removed. The electrodes were undamaged and exhibited color consistent with normal operation with the exception of the No. 3 spark plug, which was oil-soaked. The engine crankshaft was rotated using the cooling fan. Compression and suction were obtained on all six cylinders.

The oil sump screen was removed and contained two small plastic fragments consistent with the magneto drive bushings. The oil filter was removed and cut open. The internal filter element exhibited no debris.

The engine was installed on a test stand. In order to facilitate an engine run, a slave starter and propeller were installed. The engine was started and ran uneventfully. During the engine run, the No. 3 cylinder was not producing any exhaust gas temperature (EGT) readings on the engine monitoring unit installed on the test stand. The engine was shut down and further inspected. The bottom spark plug lead of the No. 3 cylinder was found impact damaged, and the upper spark plug lead was pulled away from the ignition cap. A serviceable ignition harness was installed for both the left and right magnetos. The engine was started a second time and operated throughout various power settings. At maximum power, the engine produced 2,600 rpm at 29 inches of manifold pressure. Engine rpm drops during magneto tests were within specification. The engine ran uneventfully until it was shut down using the mixture cut-off.

No evidence of any preexisting mechanical malfunction was observed with the airframe or engine.

For further information, see the Accident Site, Airframe, and Engine Examination Summary report and Robinson Helicopter's report within the public docket for this accident.


The engine prepared for an engine run.


Medical And Pathological Information

The Orange County Coroner, Santa Ana, California, performed an autopsy on the pilot. The autopsy report indicated that the cause of death was multiple blunt force traumatic injuries.

Toxicology testing on specimens recovered from the pilot performed at the FAA Forensic Sciences Laboratory identified unspecified amounts of Irbesartan in the blood and urine.

Irbesartan is a prescription medication used alone or in combination with other medications to treat high blood pressure. It is not considered to be impairing.


Magneto bushings located in the oil screen. 

Additional Information

According to the FAA's Helicopter Flying Handbook (FAA-H-8083-21B), Chapter 6, Weight and Balance:

Weight limits are necessary to guarantee the structural integrity of the helicopter, enable pilots to predict helicopter performance and insure aircraft controllability.

Helicopter performance is not only affected by gross weight, but also by the position of that weight. It is essential to load the aircraft within the allowable CG range specified in the rotorcraft flight manual (RFM) weight and balance limitations. Loading outside approved limits can result in insufficient control travel for safe operation.

The pilot should ensure that the helicopter is properly balanced within its center of gravity limitations, so that minimal cyclic input is required during hovering flight, except for any wind corrections. Since the fuselage acts as a pendulum suspended from the rotor, changing the CG changes the angle at which the aircraft hangs from the rotor…if the CG is too far forward of the mast, the helicopter hangs with its nose tilted down…

Loss of Control in Flight: Wittman W-10 Tailwind, N251WT; fatal accident occurred January 23, 2018 near Sauk Centre Municipal Airport (D39), Stearns County, Minnesota


Matthew James Skwira


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

Additional Participating Entities:

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

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


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

http://registry.faa.gov/N251WT


Location: Sauk Centre, MN
Accident Number: CEN18FA083
Date & Time: 01/23/2018, 1530 CST
Registration: N251WT
Aircraft: SKWIRA MATTHEW J W-10 TAILWIND
Aircraft Damage: Substantial
Defining Event:Loss of control in flight
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal

On January 23, 2018, about 1530 central standard time, an experimental, amateur-built W-10 Tailwind airplane, N251WT, was substantially damaged when it impacted terrain near Sauk Centre Municipal Airport (D39), Sauk Centre, Minnesota. The pilot sustained fatal injuries. The airplane was privately owned and was operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed throughout the area and no flight plan was filed for the flight, which originated from Cambridge Municipal Airport (CBG), Cambridge, Minnesota, about 1415.

According to witness statements, fuel records, and the pilot's cell phone records, the pilot fueled the airplane with about 7 gallons of fuel and departed D39 about 1200. The pilot landed at Princeton Municipal Airport (PNM), Princeton, Minnesota, about 1244 and departed about 1324. The pilot then landed at CBG about 1341 before departing about 1415. After landing at D39 about 1515, the pilot brought the airplane to a full stop on runway 32, taxied back to the end of the runway, and subsequently departed.

The approximate total flight time from when the pilot originally departed from D39 at 1200, to the time of the accident, was 2 hours 16 minutes, and the total distance flown was about 155 miles. There were no recorded radio communications from the pilot or radar information associated with the airplane. When the pilot did not return as expected, family members contacted authorities and an ALNOT was issued. The airplane wreckage was located about 0820 the next morning about 2.7 statute miles south of D39. The search was assisted by the Air Force Forensic Cellular Team. 

Pilot Information

Certificate: Private
Age: 50, 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: BasicMed None
Last FAA Medical Exam: 08/28/2017
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time:  (Estimated) 306 hours (Total, all aircraft), 19 hours (Total, this make and model), 19 hours (Last 90 days, all aircraft), 7 hours (Last 30 days, all aircraft), 2 hours (Last 24 hours, all aircraft) 

The pilot held a private pilot certificate. According to pilot logbook information provided by family members, his total flight experience was about 306 hours. No flight time was logged between July 2012 and September 2017; 24 hours were logged between September 2017 and the accident. The pilot's most recent flight review was completed on September 7, 2017. His first flight in the accident airplane was on October 25, 2017, and he had logged about 18 hours in the airplane before the accident. The pilot did not hold a Federal Aviation Administration (FAA) airman medical certificate but reported that he had completed the requirements for operation under BasicMed on August 28, 2017. 

Aircraft and Owner/Operator Information

Aircraft Make: SKWIRA MATTHEW J
Registration: N251WT
Model/Series: W-10 TAILWIND NO SERIES
Aircraft Category: Airplane
Year of Manufacture: 2017
Amateur Built: Yes
Airworthiness Certificate: Experimental
Serial Number: 1
Landing Gear Type: Tricycle
Seats: 2
Date/Type of Last Inspection: 09/20/2017, Condition
Certified Max Gross Wt.: 1425 lbs
Time Since Last Inspection: 23 Hours
Engines:1 Reciprocating
Airframe Total Time:  as of last inspection
Engine Manufacturer: Lycoming
ELT: Installed, not activated
Engine Model/Series: O-320B1A
Registered Owner: On file
Rated Power: 160 hp
Operator: On file
Operating Certificate(s) Held: None

The airplane, a Wittman Tailwind, was constructed of a steel tube fuselage and wooden wing structure covered with fabric. The airplane was built by the pilot and received its special airworthiness certificate from the FAA on September 20, 2017. According to FAA documents, no defects were noted during the initial airworthiness certification/inspection. The airplane was powered by a Lycoming O-320-B1A engine equipped with a wooden propeller. According to the engine manufacturer's operating manual, the engine consumed about 10 gallons of fuel per hour. Friends of the pilot stated that the pilot usually kept his fuel tank topped off. The fuel tank capacity of the airplane was 32 total gallons.

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: D39, 1242 ft msl
Distance from Accident Site: 3 Nautical Miles
Observation Time: 1535 CST
Direction from Accident Site: 360°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 3 knots /
Turbulence Type Forecast/Actual: / None
Wind Direction: 350°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 30.09 inches Hg
Temperature/Dew Point: -3°C / -9°C
Precipitation and Obscuration:
Departure Point: Cambridge, MN (CBG)
Type of Flight Plan Filed: None
Destination: Sauk Centre, MN (D39)
Type of Clearance: None
Departure Time: 1415 CDT
Type of Airspace: Class E

The reported weather at D39 about the time of the accident included clear skies, 10 miles visibility, and wind from 350° at 3 knots.

Airport Information

Airport: Sauk Municipal (D39)
Runway Surface Type:
Airport Elevation: 1242 ft
Runway Surface Condition: Dry; Ice
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: None

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 45.659722, -94.930278 

The accident site was located in a large plowed field. The left side of the cabin structure had been moved by first responders. There was no evidence of a postcrash fire and there was no odor of fuel at the site. There was no evidence in the surrounding area of impact with any obstructions prior to ground impact. Signatures at the site indicated that the airplane impacted the ground in an approximate 45° nose-down, wings-level attitude. The cockpit and front structure of the cabin were mostly destroyed by impact forces. The leading edges of both wings were destroyed. The empennage was bent slightly forward and crumpled along its longitudinal length. The fuel tank and fuel lines were compromised. One propeller blade was visible and was relatively undamaged. The second propeller blade was found shattered underneath the engine. The right elevator was found separated from the elevator control system and moved freely. The left elevator was in the full down position and could not be moved.

The engine crankshaft was rotated by hand and drivetrain continuity was established from the propeller to the gearbox. Thumb compression was established on all cylinders. The spark plugs exhibited normal wear patterns. The left and right magnetos were removed but could not be tested due to impact damage. The oil sump was found broken; the engine exhaust and intake pipes were crushed up and aft. The crankshaft flange was deformed, and the starter ring was broken. The oil cooler was crushed aft. The throttle and mixture cables were broken due to impact damage. The carburetor was impact damaged and could not be tested. The fuel lines were compromised by impact damage. No mechanical anomalies were found during the engine examination.

Access panels and fabric were removed to facilitate a detailed flight control examination. Flight control continuity was established from the cockpit to all control surfaces, except the connection to the right elevator control horn. The control horn was found fractured adjacent to a weld joint. The left elevator was connected and appeared undamaged. Examination of the right elevator tubular frame revealed fractures consistent with overstress. Similar overstress fractures were found on the left elevator tubular frame. The overstress fractures were consistent with impact forces. The right elevator skin adjacent to its attachment hinges showed marks consistent with overtravel. The attachment hinges for the left elevator revealed evidence of overtravel in the downward direction. The overstress fractures and overtravel marks were consistent with impact forces. No other anomalies were found during the airframe examination.

Medical And Pathological Information

The Ramsey County Medical Examiner's Office, St. Paul, Minnesota, performed an autopsy of the pilot. The cause of death was blunt trauma. Toxicology testing performed at the FAA Forensic Sciences Laboratory identified no tested-for drugs, ethanol, or carbon monoxide.