Friday, November 27, 2020

Loss of Control in Flight: Cessna 172R Skyhawk, N994CP; fatal accident occurred July 06, 2019 near University-Oxford Airport (KUOX), Lafayette County, Mississippi

































Aviation Accident Final Report - National Transportation Safety Board

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

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Jackson, Mississippi
Lycoming Engines; Williamsport, Pennsylvania
Textron Aviation; Wichita, Kansas
Civil Air Patrol; Maxwell AFB, Alabama
Civil Air Patrol; Columbus, Mississippi

Investigation Docket - National Transportation Safety Board:

Civil Air Patrol


 Location: Oxford, Mississippi 
Accident Number: CEN19FA212
Date & Time: July 6, 2019, 15:15 Local
Registration: N994CP
Aircraft: Cessna 172
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General aviation - Instructional

Analysis

The student pilot was conducting a solo cross-country flight and was heard on the common traffic advisory frequency announcing her intention to land at the destination airport. A witness at the airport indicated that the pilot's voice sounded "panicked" and that she did not finish her sentences. The pilot did not respond to a request for the airplane’s location from a helicopter in the area. The witness saw the airplane approach the runway with a tailwind present. Additionally, recorded wind was consistent with a quartering tailwind. The airplane did not touch the runway and about midfield, started to climb at a "steep" angle. The witness indicated that he did not hear any engine anomalies. He stated that the airplane veered toward the golf course and then went "straight down behind the trees."

A witness at the golf course first saw the airplane above the trees and stated that it appeared to be "struggling" to maintain airspeed, was nose up, and appeared to be “very close to stalling.” The witness indicated that the airplane then made a hard left turn and lost altitude, struck the ground, and slid to nearby trees. A ground fire subsequently occurred.

Postaccident examination of the wreckage and engine revealed migration of molten metal under the No. 4 exhaust valve. However, no preimpact anomalies that would have prevented normal operation of the airplane were detected. The flap jackscrew did not exhibit any thread extension, which is consistent with retracted flaps.

Based on the available information, it is likely that the student pilot did not maintain airplane control during an attempted go-around with a tailwind, and the airplane subsequently impacted terrain during an uncontrolled descent.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The student pilot's failure to maintain airplane control during a go around with a tailwind, which resulted in an uncontrolled descent and impact with terrain.

Findings

Personnel issues Aircraft control - Student/instructed pilot
Environmental issues Tailwind - Contributed to outcome
Aircraft (general) - Not attained/maintained

Factual Information

History of Flight

Approach-VFR go-around Loss of control in flight (Defining event)
Uncontrolled descent Collision with terr/obj (non-CFIT)

On July 6, 2019, about 1515 central daylight time, a Cessna 172R, N994CP, was destroyed when it was involved in an accident near Oxford, Mississippi. The student pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight.

The solo cross-country flight originated from Golden Triangle Regional Airport (GTR), Columbus, Mississippi, about 1400 and was destined for University-Oxford Airport (UOX), Oxford, Mississippi. A fixed-base operator employee at UOX reported that, about 1515, he heard the pilot announce on the common traffic advisory frequency that the airplane was landing on runway 9. He stated that the pilot's voice sounded "panicked" and that she did not finish her sentences. The pilot did not respond to a request for the airplane’s location from a helicopter in the area. The witness saw the airplane approach runway 9 with a tailwind. The airplane did not touch the runway, and abeam the windsock near midfield, the airplane started to climb at a "steep" angle. The witness indicated that he did not hear any engine anomalies. He stated that the airplane veered toward the golf course and then went "straight down behind the trees." He observed smoke about 3 minutes later above the treeline. The witness advised that a local Federal Aviation Administration (FAA) air traffic control center had called a few minutes before the landing attempt and was trying to locate the airplane.

A witness at the golf course reported that he first saw the airplane above the trees over the 16th hole of the golf course; the airplane appeared to be "struggling" to maintain airspeed, was nose up, and appeared to be “very close to stalling.” The witness indicated that the airplane then made a hard left turn and lost altitude. He thought the airplane was attempting a landing on
the 17th fairway. The airplane continued the left turn, struck the ground, and slid to nearby trees.

The witness statements are consistent with the plotted radar data.

Good Samaritans and first responders tried to extract the pilot from the cockpit to no avail; the seatbelt and shoulder harness retained the pilot in the cockpit. A ground fire subsequently occurred. Firefighters contained the fire, and the pilot was extracted and airlifted to a hospital.

Pilot Information

Certificate: Student
Age: 18,Female
Airplane Rating(s): None
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): None 
Second Pilot Present: No
Instructor Rating(s): None 
Toxicology Performed: Yes
Medical Certification: Class 3 Without waivers/limitations
Last FAA Medical Exam: October 1, 2018
Occupational Pilot: No 
Last Flight Review or Equivalent:
Flight Time: (Estimated) 69.4 hours (Total, all aircraft), 30.2 hours (Total, this make and model), 32.7 hours (Last 90 days, all aircraft), 16.7 hours (Last 30 days, all aircraft), 1.2 hours (Last 24 hours, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: Cessna 
Registration: N994CP
Model/Series: 172 R
Aircraft Category: Airplane
Year of Manufacture: 1997 
Amateur Built: No
Airworthiness Certificate: Normal 
Serial Number: 17280318
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection: June 21, 2019 Annual
Certified Max Gross Wt.: 2550 lbs
Time Since Last Inspection: 
Engines: 1 Reciprocating
Airframe Total Time: 2849 Hrs at time of accident 
Engine Manufacturer: Lycoming
ELT: C126 installed, activated, did not aid in locating accident
Engine Model/Series: IO-360
Registered Owner: 
Rated Power:
Operator:
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual (VMC) 
Condition of Light: Day
Observation Facility, Elevation: KUOX,452 ft msl
Distance from Accident Site: 1 Nautical Miles
Observation Time: 15:15 Local 
Direction from Accident Site: 262°
Lowest Cloud Condition: Few / 3400 ft AGL
Visibility 9 miles
Lowest Ceiling: 
Visibility (RVR):
Wind Speed/Gusts: 11 knots / 
Turbulence Type Forecast/Actual:  /
Wind Direction: 310° 
Turbulence Severity Forecast/Actual:  /
Altimeter Setting: 30.04 inches Hg
Temperature/Dew Point: 32°C / 21°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Columbus/W Point/Starkville, MS (GTR)
Type of Flight Plan Filed: VFR
Destination: Oxford, MS (UOX) 
Type of Clearance: VFR flight following
Departure Time: 14:00 Local
Type of Airspace: Class G

Airport Information

Airport: University-Oxford UOX
Runway Surface Type: Asphalt
Airport Elevation: 452 ft msl 
Runway Surface Condition: Dry
Runway Used: 09 
IFR Approach: None
Runway Length/Width: 5600 ft / 100 ft
VFR Approach/Landing: Go around; Stop and go; Traffic pattern

UOX, located approximately two miles northwest of downtown Oxford, Mississippi, was a publicly owned, non-towered airport, which was owned by the University of Mississippi. Runway 9 was marked as a non-precision approach runway. It was serviced by a four-light precision approach path indicator on the runway's left side. Comments for runway 9 did not indicate that there were obstructions in reference to the runway.

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries:
Aircraft Fire: On-ground
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal 
Latitude, Longitude: 34.387779,-89.530555(est)

The airplane came to rest on a golf course about 1,200 ft north of the runway 9 centerline. The airplane resting heading was about 170°. A ground scar consistent with a left main landing gear impression was observed about 70 ft north of the wreckage, and abeam the ground scar to the east was a depression consistent with left wing contact. A ground scar consistent with a cowling and nose landing gear impression was found about 58 ft north of the wreckage. Retaining clips consistent with nose landing gear clips were found near this scar, and the scar exhibited a depression consistent with a propeller strike. The fuselage's center section was found melted, deformed, and discolored by fire. Sections of the left and right wing struts were found under their wings. The outboard section of the left wing was deformed and wrinkled upward and rearward, which was consistent with ground contact. The empennage was found upright. The engine and its attached propeller were found inverted, and the engine was partially connected to the firewall underneath the forward fuselage. An outboard section of one propeller blade was melted, and the other propeller blade exhibited forward bending.

An on-scene examination of the airplane was conducted. Flight control cables were traced, and control continuity was established to all control surfaces from the cockpit area. Engine control cables were traced, and control continuity was established from the cockpit area to the engine. Removed sparkplugs exhibited a normal combustion appearance when compared to a Champion Aviation Check-A-Plug chart. The engine exhibited a thumb compression at three cylinders when the crankshaft was rotated. All rocker covers were removed, and all valve train components moved accordingly when the crankshaft was rotated. The No. 4 cylinder was removed and had material under its exhaust valve. Oil was observed within the engine crankcase when the cylinder was removed. No debris was observed in the oil screen, oil filter, and fuel servo screen. The rear-mounted engine accessories exhibited deformation and discoloration consistent with thermal fire damage. The flap jackscrew did not exhibit any thread extension, which is consistent with retracted flaps.

The No. 4 cylinder was examined at the National Transportation Safety Board Materials Laboratory. The examination revealed that the cylinder components were discolored with deposits on the surface consistent with fire damage. A section of deformed exhaust riser was attached to the cylinder assembly, and a gap was present where the riser attached to the cylinder head. The exhaust valve was slightly open with a gap between the valve head and the valve seat. A gray deposit was observed within the gap on the upper side of the exhaust valve. The exhaust valve was disassembled from the cylinder assembly. Dull gray deposits with smooth surface features were observed around the valve stem and on the valve head and were consistent with previously molten aluminum alloy. The shape of the deposit was consistent with flow over the lower side of the valve stem, accumulating on the upper surfaces of the exhaust port and valve seat.

Medical and Pathological Information

According to the Office of the State Medical Examiner, Pearl, Mississippi, autopsy report, the cause of the pilot's death was multiple blunt trauma. The medical examiner reported evidence of medical interventions. There was no evidence of any significant natural disease. Toxicology testing performed at the FAA Forensic Sciences Laboratory on the pilot’s blood and urine revealed ketamine and norketamine, its metabolite. Medical records obtained from the helicopter air ambulance service indicated that ketamine was administered to the pilot for pain management while en route to the hospital.
 
Elizabeth "Lake" Little 
 February 12, 2001 - July 06, 2019

Ed Malinowski,  Investigator In Charge 
National Transportation Safety Board






16 comments:

  1. Tragic story. Lots of comments in original posting.

    http://www.kathrynsreport.com/2019/07/cessna-172r-skyhawk-n994cp-fatal.html#comment-form

    ReplyDelete
  2. like the accident never happen
    Welcome to the NTSB Accident Docket Search
    @ https://data.ntsb.gov/Docket/Forms/searchdocket
    Accident Number: CEN19FA212 
    Docket Search Result: 0 Dockets Feedback
    © 2020 - National Transportation Safety Board

    OR
    State/Region Mississippi Oxford Mode Aviation
    Accident/Occurrence Date - From: 07/06/2019 To: 07/06/2019
    Docket Search Result: 0 Dockets Feedback
    © 2020 - National Transportation Safety Board

    ReplyDelete
    Replies
    1. No docket, but "CAROL" search does show pdf link to report for this accident. The hyperlink for "Investigation Docket" at the end of the report goes to a blank page for 99776 project docket. Maybe there was new or updated info for the docket and it will show up later.

      https://data.ntsb.gov/carol-main-public/basic-search

      Delete
    2. The status of CEN19FA212 is "in-work", not completed as yet. The NTSB is working on the approval of dockets before releasing to the public. NTSB investigators are known for their patience, meticulousness, and objectivity.

      Delete
  3. There's a lot of reasons one could be 70 hours and not yet have their ticket, but it certainly makes one at least curious if there were basic airmanship issues she was trying to train though. Very sad regardless.

    ReplyDelete
  4. looks like a long hiatus and then trying to finish her ticket. Too many things she was doing at the same time? Beauty pageant, sports and trying to be a pilot.

    ReplyDelete
  5. 14 CFR § 61.93 Solo cross-country flight requirements.
    (there are many)

    (d) Limitations on authorized instructors to permit solo cross-country flights. An authorized instructor may not permit a student pilot to conduct a solo cross-country flight unless that instructor has:

    (1) Determined that the student's cross-country planning is correct for the flight;

    (2) Reviewed the current and forecast weather conditions and has determined that the flight can be completed under VFR;

    (3) Determined that the student is proficient to conduct the flight safely;

    (4) Determined that the student has the appropriate solo cross-country endorsement for the make and model of aircraft to be flown; and

    (5) Determined that the student's solo flight endorsement is current for the make and model aircraft to be flown.


    (e) Maneuvers and procedures for cross-country flight training in a single-engine airplane. A student pilot who is receiving training for cross-country flight in a single-engine airplane must receive and log flight training in the following maneuvers and procedures:

    (1) Use of aeronautical charts for VFR navigation using pilotage and dead reckoning with the aid of a magnetic compass;

    (2) Use of aircraft performance charts pertaining to cross-country flight;

    (3) Procurement and analysis of aeronautical weather reports and forecasts, including recognition of critical weather situations and estimating visibility while in flight;

    (4) Emergency procedures;

    (5) Traffic pattern procedures that include area departure, area arrival, entry into the traffic pattern, and approach;

    (6) Procedures and operating practices for collision avoidance, wake turbulence precautions, and windshear avoidance;

    (7) Recognition, avoidance, and operational restrictions of hazardous terrain features in the geographical area where the cross-country flight will be flown;

    (8) Procedures for operating the instruments and equipment installed in the aircraft to be flown, including recognition and use of the proper operational procedures and indications;

    (9) Use of radios for VFR navigation and two-way communication, except that a student pilot seeking a sport pilot certificate must only receive and log flight training on the use of radios installed in the aircraft to be flown;

    (10) Takeoff, approach, and landing procedures, including short-field, soft-field, and crosswind takeoffs, approaches, and landings;

    (11) Climbs at best angle and best rate; and

    (12) Control and maneuvering solely by reference to flight instruments, including straight and level flight, turns, descents, climbs, use of radio aids, and ATC directives. For student pilots seeking a sport pilot certificate, the provisions of this paragraph only apply when receiving training for cross-country flight in an airplane that has a VH greater than 87 knots CAS.

    ReplyDelete
    Replies
    1. Did you not think CAP was aware of 61.93? If they weren’t aware, then this post is relevant. It’s very doubtful her CFI missed this.

      Delete
  6. Does the CAP allow student pilots to fly their planes?

    ReplyDelete
    Replies
    1. Yes, as stated in CAPR 70-1 at:
      https://nesa.cap.gov/media/cms/CAPR_701_31_Mar_2020_63F838B8EAFDE.pdf

      6.2.Eligibility for Flight Instruction

      6.2.2.CAP Cadets, qualified CAP Transport Mission Pilots and CAP Mission Pilots are authorized to use CAP airplanes for flight instruction toward any FAA certificate, rating, or endorsement.

      Also:
      6.1.3.CAP members may not charge for any ground instruction or flight training accomplished in accordance with this regulation.

      Delete
    2. Who covers the costs for flight training?

      Delete
    3. Miami Squadron info at link below says PIC pays cost of airplane.

      http://units.flwg.us/FL076/information/flying-with-the-cap.aspx

      Delete
    4. As far as the cost of flight training, the answer is it depends. A senior member must hold at least a private pilot certificate in order to fly a CAP aircraft, but they are able to use the aircraft for to train for advanced ratings at their expense. There is a set hourly rate for the aircraft and the pilot is responsible for paying for his or her own fuel. There are several scholarship programs to assist the cadets with their flight training both inside and outside of CAP. These programs are highly selective and require that the cadet complete their FAA written, and in many cases, first solo before being awarded a scholarship to complete their training.

      Delete
  7. The final NTSB report has been released.
    The National Transportation Safety Board determines the probable cause(s) of this accident to be:The student pilot's failure to maintain airplane control during a go around with a tailwind, which resulted in an uncontrolled descent and impact with terrain.

    ReplyDelete
    Replies
    1. Where is a link to this actual report? I cannot find anything through the NTSB database. Thanks.

      Delete
    2. You have search CAROL on the NTSB accident database for N994CP. It doesn't allow a copy and paste link since the updated to the new system. https://data.ntsb.gov/carol-main-public/basic-search

      Delete

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