Thursday, December 10, 2020

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

Elizabeth "Lake" Little































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.

Ed Malinowski,  Investigator In Charge 
National Transportation Safety Board







23 comments:

  1. what was accomplished during the student pilot's "16.7 hours (Last 30 days, all aircraft) was not of concern, or addressed!
    In conclusion, 'approach runway 9 with a tailwind .. did not touch the runway, and abeam the windsock near midfield started to climb at a "steep" angle .. veered toward the golf course and then went "straight down behind the trees.'

    ReplyDelete
  2. Just a damn shame, this accident. A real heartbreaker to read. There isn't anything in this world that can bring this young lady back - it's a terrible pity she seems not to have been completely prepared for this flight though her CFI had no reservations about her flying it - or perhaps she was and had a moment of panic during the landing attempt. Surely there had to be some way to prevent this from happening. Either way it's just awful - condolences to her loved ones, family, and friends.

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  3. Anyone else notice this, it reads like ATC called before the accident even happened "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."

    ReplyDelete
    Replies
    1. Very much agree. Something was up before we ever get to the accident sequence, like maybe something with the VFR flight plan? Or, more likely, flight following having been in progress and the student switching off frequency without telling the controller? It is important to find out what was done with ATC that resulted in their call because that may shed additional light on how well-trained and experienced procedurally this student was before being signed off for this flight.

      Delete
  4. I totally agree with the ATC commentary above!
    It's the *flight instructors* who were oblivious. Same thing with N2987Z...
    http://www.kathrynsreport.com/2020/12/collision-during-takeoff-bellanca-7eca.html

    "Anyone else notice this, it reads like ATC called before the accident even happened..."

    ReplyDelete
  5. Reading from the docket, several golf course witnesses mention very windy, so it was not a good day for the downwind landing mistake.

    Descriptions of efforts to free the pilot make you wonder if harnesses should have a web belt cutter tool attached. Those who tried to free her will have that trapped in fire horror in their memories forever.

    https://data.ntsb.gov/Docket/Document/docBLOB?ID=8141881&FileExtension=pdf&FileName=Statements%20from%20plane%20crash_Redacted-Rel.pdf

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    Replies
    1. I have been thinking about this ever since I read the 'Good Samaritans had trouble extracting the pilot. I think it is mandatory in rescue operations at racetracks. Maybe it should be standard equipment in all rescue equipment. The medical and pathological report did not list thermal or smoke inhalation as a contributing COD. Even if they were able to extract her in time the blunt force trauma injuries were too severe!

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  6. Sad story, leading to some questions on proper training and preparing for a cross country flight.

    In an earlier version of the discussion on this accident:

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

    there had been speculation whether the lack of compression of the fourth cylinder contributed to the accident. In the final NTSB report, that question is now also resolved: The material that was stuck under the valve and that was causing the loss of compression was introduced post accident. It was a result of the post accident fire,which must have been intense, judging from all the molten material.

    The question about the ATC inquiry is a bit curious and makes one ponder. Apparently ATC was expecting her to be back on frequency sooner. They left her on the same transponder code and probably thought that she would not make a full stop landing but rather fly a missed approach judging from the ATC transcript.

    Phascolarctos.

    ReplyDelete
  7. from the photos, flaps were extended, possible in the hurried process of the transition it appears a "reset of the pitch trim or reposition wing flaps for the takeoff" was not complete, resulting in the "climb at a "steep" angle"

    ReplyDelete
    Replies
    1. Flaps were not left extended. NTSB report specifically stated "The flap jackscrew did not exhibit any thread extension, which is consistent with retracted flaps."

      Delete
  8. read and we see apparent similarities. https://www.aopa.org/news-and-media/all-news/2018/january/flight-training-magazine/ten-things-student-pilots-do-wrong

    "Many students are not doing the cruise checklist after reaching their planned en route altitude, and they are failing to use the prelanding checklist at the destination"

    "Staring inside the cockpit

    "Things With glass cockpits, it is easy to understand why both student pilots and advanced pilots may spend too much time staring at what appears to be a really interesting video game on the aircraft’s primary flight display."

    "Poor radio communications"

    "Overshooting final approach"

    "Flaring too early or too late"

    ReplyDelete
    Replies
    1. This airplane did not have a glass cockpit. It was a 1997 model steam gauge 172. The photo in the article with the G1000 is either a new (post-2015)172 or a 182.

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    2. Just my opinion, but I think she got low and slow and raised the flaps completely instead of leaving them at one notch until the airplane was climbing safely. The eight knot difference in stall speed between flaps 10 and no flaps made all the difference in flying and not flying in this case.

      Delete
  9. I cannot imagine the feeling of trying to rescue this young woman still strapped to her seat and you can't because of the fire. That is too horrific to even ponder and I know I'd never be the same after that having the guilt that I just couldn't get in there. So horribly tragic.

    That said, why was she still just a student solo at 70 hours and what tests did her instructor really push on her? Sounds like she was letting the plane fly her, not the other way around as it is supposed to be and you are trained for. So sad all the way around.

    ReplyDelete
  10. If you commenters want to point out problems, how about starting with the owners and operators of the aircraft and flight school. I would like to know how many pilots they have successfully trained from solo to check ride. Also, who pays for this training? Future pilot trainees should be advised to go to a proven professional flight school to obtain ppl and ratings. This was a very unfortunate accident. The victim only trying to pursue a dream and a goal. Need to take a hard look at this program.

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    Replies
    1. Approximately 65 CAP Cadets have completed the zero time to Private Pilot program over the past two years. It is a very selective scholarship based program that includes training using CAP aircraft and instructors, local flight schools, week-long summer flight academies for initial training and possible solo and an eight week summer in residence program at Purdue University.

      Delete
    2. And who pays for cap airplane and instructors? I never seem to get an answer to this question. I do know that many of the beneficiaries of this training are not selected on merit, but more on who they know. CAP on our field has isolated itself from the public. Joining nearly an impossibility as they already have all the pilots they need. They also keep making many amateur errors new pilots make. Need to have a system that is fair to all who want to earn the ppl. They also need to pay a share of their training. I would like to know what it actually costs the taxpayer to train these 65 cadets. You probably could have gotten them compete ATP’s for much less at a private flight college. Also, this program would compete with the same schools but with lower or no costs. Caps existence is reliant upon taxpayer funds and a political lobby in Congress.

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    3. So......Robertcall3......rather than throw spears at the local CAP about who they select for training and who pays for it......why not tell us your story about not being selected and how you have dealt with that rejection emotionally.

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    4. Cost never recognized when you are not paying the bill. Reminds me of taxpayers support of Amtrak. One study showed you could put each passenger into a cab and drive them from east coast to west coast and the fair would be less than what the true costs for Amtrak to do the same. Private school 65 ppl’s would cost at the most $10,000 or less each estimate. Many much less. CAP budget $100 plus million (guess). Cost per ppl by CAP unknown because they aren’t concerned.
      I doubt any of thier graduates are professional pilots.

      Delete
  11. I noticed another recent incident involving a couple of CFI’S from same company. Worth reviewing on this site from a training perspective. Nov. 25, 2020

    Cessna 172N Skyhawk, N23NJ: Accident occurred November 24, 2020 near Central Jersey Regional Airport (47N), Manville, Somerset County, New Jersey

    ReplyDelete
    Replies
    1. This incident, was reportedly 2 CAP instructors, one injured in a landing of a C172. Report very brief but looked preventable unless mechanical problem. Would these be same CFI’S if someone kid got into this program with same goal as this young lady was pursuing?

      Another recent incident involving newly minted young pilot and also CAP member in a C150 flown in bad weather resulting in 2 fatalities. Unfortunate that their name CAP keeps showing up on these incidents. Many others if you search this site, including gliders and C182’s.

      I know when a flight school begins to have many incidents, they require the school to come with an over site plan to help prevent these incidents. Could be helpful here.

      Delete

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