Saturday, April 18, 2020

Loss of Control in Flight: Robinson R44 Raven, N616HS; fatal accident occurred July 08, 2018 near Williamsburg-Jamestown Airport (KJGG), Virginia

Accident Site 


Helicopter – View of Left Side


Helicopter – View of Right Side 


Helicopter – View of Bottom 

Map of ADSB Tracking Data
















A retired Army officer, Henry Schwarz was president of the Virginia Helicopter Association. In this 2015 photograph, Schwarz stood in front of the Robinson R44 Raven II he later crashed in.

Jean Lonchak Danylko 








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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Richmond, Virginia
Robinson Helicopter Inc; Torrence, California Lycoming Engines; Williamsport, Pennsylvania 

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


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

http://registry.faa.gov/N616HS 

Location: Williamsburg, VA
Accident Number: ERA18FA187
Date & Time: 07/08/2018, 1633 EDT
Registration: N616HS
Aircraft: Robinson R44
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight
Injuries: 2 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

On July 8, 2018, about 1633 eastern daylight time, a Robinson R44-II, N616HS, was destroyed when it was involved in an accident in Williamsburg, Virginia. The pilot and one person on the ground were fatally injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.

The pilot had flown from Stafford Regional Airport (RMN), Stafford, Virginia, to Williamsburg Jamestown Airport (JGG), Williamsburg, Virginia, earlier that morning to attend a meeting at JGG. Airport personnel reported that the helicopter had been refueled to capacity before the pilot departed on the return flight to RMN.

Automatic dependent surveillance-broadcast (ADS-B) data showed that the helicopter departed JGG about 1630, then turned north. The helicopter climbed to a pressure altitude about 1,700 ft. After reaching 1,700 ft, the helicopter leveled off and the groundspeed increased from about 60 knots to about 110 knots over the next 1.5 minutes. The helicopter then entered a right, decreasing-radius, turning descent that continued until tracking coverage was lost. At the last recorded position, the helicopter was in the vicinity of the accident site, descending at a rate greater than 10,000 ft per minute.

Several witnesses near the accident site described the helicopter as flying low; one estimated its height about 100 ft above the ground as it approached a two-story condominium complex. They described it as flying relatively straight and level, or slightly descending, before suddenly pitching nose down and descending into the roof of the building. One witness described the helicopter as "rocking back and forth unsteadily" just before it pitched downward. Another witness, located about 300 ft south of accident site, recalled the engine making a "constant sound" as it flew over his head.

The helicopter impacted a condominium building located about 3 nautical miles north of JGG.

Pilot Information

Certificate: Commercial
Age: 85, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s): Helicopter
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: None None
Last FAA Medical Exam:
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time:  (Estimated) 5693 hours (Total, all aircraft), 545 hours (Total, this make and model)

According to Federal Aviation Administration (FAA) airman records, the pilot did not possess a valid medical certificate at the time of the accident. His application for a medical certificate in 2016 was deferred to the FAA for evaluation of his recent surgical interventions for tremors related to Parkinson's disease. As recently as April 2018, the FAA denied issuing a medical certificate due to the pilot's cognitive impairment and Parkinson's disease.

The last entry in the pilot's logbook was a round-trip flight from RMN to JGG in December 2017. Although not logged as such, that flight was with an instructor, according to a witness statement. During doctor visits in 2017 and 2018, he reported that his last flight was on August 1, 2016.

Aircraft and Owner/Operator Information

Aircraft Make: Robinson
Registration: N616HS
Model/Series: R44 II
Aircraft Category: Helicopter
Year of Manufacture: 2004
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 10449
Landing Gear Type: Skid;
Seats: 4
Date/Type of Last Inspection: 08/24/2017, Annual
Certified Max Gross Wt.: 2500 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 619 Hours as of last inspection
Engine Manufacturer: Lycoming
ELT: Installed
Engine Model/Series: IO-540-AE1A5
Registered Owner: On file
Rated Power: 260 hp
Operator: On file
Operating Certificate(s) Held: None

The most recent recorded maintenance was an oil change performed on January 26, 2018, at an airframe and engine total time of 649 hours, and 35 hours since engine overhaul. The airframe total time at the time of the accident could not be determined.

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light:Day 
Observation Facility, Elevation: JGG, 49 ft msl
Distance from Accident Site: 3 Nautical Miles
Observation Time: 1635 EDT
Direction from Accident Site: 168°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: Calm /
Turbulence Type Forecast/Actual:
Wind Direction:
Turbulence Severity Forecast/Actual:
Altimeter Setting: 30.27 inches Hg
Temperature/Dew Point: 29°C / 10°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Williamsburg, VA (JGG)
Type of Flight Plan Filed: None
Destination: Stafford, VA (RMN)
Type of Clearance: None
Departure Time:1630 EDT 
Type of Airspace: Class G 

Airport Information

Airport: Williamsburg-Jamestown (JGG)
Runway Surface Type: N/A
Airport Elevation: 49 ft
Runway Surface Condition:
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: None 

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: On-Ground
Ground Injuries: 1 Fatal
Aircraft Explosion: None
Total Injuries: 2 Fatal
Latitude, Longitude: 37.288333, -76.729444 

The main wreckage came to rest inside the north end of the building, with some components, including a section of the tail rotor drive shaft, found along the 70-ft wreckage path extending from the building on a heading of about 20° magnetic. All the major components of the helicopter were present at the accident site except for the tail boom. The vertical stabilizer, aft bulkhead, and a section of the tail rotor guard were located; however, building damage prevented access to several areas surrounding the main wreckage. Many of the components were partially or completely consumed by a post-crash fire. Remnants of the removable copilot side controls were found near their stowed position. Remnants of all pilot side controls were present. All hydraulic controls were identified, with portions of all push-pull rods extending from the hydraulic actuators. Portions of the flight control rods were thermally damaged. All main and tail rotor flight control rod ends were secure to their attachment points at both ends, except for the tail rotor gear box connection, which was not recovered. The transmission input sheave (pulley) was manually rotated in both the locking and freewheeling modes, and the main rotor drive shaft rotated with the sheave, with some interference from a damaged flex coupling. A score mark on the aft face of the upper sheave was about 4 inches long in the direction of rotation. The leading edges of both main rotor blades were dented and bent in several locations and remained attached to the rotor hub. Most of the remainder of the main rotor blades were consumed by fire. The tail rotor gearbox mounting bolts were fractured consistent with overload. The transmission continuity was confirmed from the upper sheave to the main rotor mast and to the intermediate flex coupling. The main and auxiliary fuel tanks were severely damaged. The main tank cap was in place; the auxiliary tank cap was missing. Portions of the main and auxiliary fuel tanks were consumed by post-crash fire. The tail rotor gearbox, remnants of tail rotor blades, and remnants of the main rotor tips were found near the location of the main wreckage during a subsequent search of the accident site in October 2018.

The engine crankshaft rotated freely by hand. The crankshaft gear index pin was sheared, and the gear bolt was found mostly unthreaded. The locking tab on the bolt head was found in place against the bolt head. After securing the gear in place, valvetrain and continuity from the engine crankshaft to the accessory section was confirmed. A subsequent examination of the crankshaft gear bolt, locking tab, and accessory gears in the NTSB Materials Laboratory revealed no preimpact damage or anomalies. The engine accessory case cover, which covers the crankshaft gear and accessory gears, was impact damaged and partially missing. The engine was oriented in the helicopter with the accessory case facing forward. Both oil coolers, one on each side of the engine, exhibited grinding damage in line with the starter ring gear. Thumb compression and suction were present on all cylinders, though weaker on cylinder No. 5. The cylinder head and intake pipe for cylinder No. 5 displayed impact damage, and debris was found in the intake. All spark plugs exhibited normal wear and coloration when compared to the Champion check-a-plug chart; the Nos. 4 and 6 bottom spark plugs were oil-soaked. Both magnetos were impact and fire damaged and could not be functionally tested. Borescope inspection of all cylinders revealed no damage or scoring marks on piston tops, cylinder walls, or valves. The fuel injection servo inlet screen was free of debris. The butterfly valve was found in the full-open position; however, the input control rod was damaged and not connected. Impact damage to the mixture control actuator precluded determination of its position. The mixture control knob in the cockpit was found in the full-rich position. All six fuel injector nozzles were found unobstructed.

Medical And Pathological Information

An autopsy of the pilot was performed by the Office of the Chief Medical Examiner, Central District of Virginia. The pilot's cause of death was blunt force trauma.

Toxicology testing performed on the pilot by the FAA Forensic Sciences Laboratory identified 0.032 grams per deciliter (gm/dL) of ethanol in kidney tissue and no drugs or ethanol in muscle. The finding of ethanol in kidney tissue but not muscle is consistent with postmortem production.

The 85-year-old pilot had a long history of progressive upper extremity tremor that he had reported to the FAA. According to personal medical records, the pilot had been diagnosed with a parkinsonian syndrome in April 2015. Treatment with medication resulted in some improvement of his symptoms. He subsequently had a deep brain stimulator (DBS) implanted that improved his right-hand tremor. Neuropsychological evaluations performed pre- (September 2015) and post- (August 2016) surgery determined increased cognitive decline to mild cortical dementia; cognitive decline can be a side-effect of the surgery. After the surgery, the pilot reported that his right-hand tremors had improved, but worsened later in the day, attributed to fatigue. The neuropsychological testing in August 2016 determined that the pilot was not insightful about his cognitive issues and that he had worsening of psychomotor speed and attention. In a letter written to the FAA in September 2016, the pilot's neurologist recommended that he not fly due to his dementia. The pilot was started on medication to treat the dementia. The pilot began seeing a new neurologist in June of 2017 when he informed the neurologist of his desire to return to flight status and he complained of tremors and memory difficulties. The second neurologist concurred that the pilot should not fly and should only drive short distances because he was concerned about the pilot's reaction time and judgment. The neurologist ordered physical therapy.

In an August 2017 visit to the neurologist, the pilot reported having had six motor vehicle accidents through the spring of that year, and was having constant daily left hand tremors and imbalance. Left hand resting tremors, which were greater than the right hand, were noted. A follow-up evaluation found improvement from previous testing with evidence of mild cognitive impairment instead of dementia. Also noted was that the pilot had impaired measures of simple attention and visual scanning and tracking speed and mild, relative difficulty with sustained attention. The pilot reported self-discontinuing his medication for dementia in September 2017 because of a letter from the FAA that stated, "that as long as he used the patch, he would not be able to receive a flying license." At numerous physician office visits, the pilot had reported difficulty with tremors, balance, and memory. A driver rehab evaluation performed in October 2017 noted below-normal dynamic vision and vision information processing. The pilot demonstrated deficits in both sustained and divided attention. A driving restriction of "drive within a 15-mile radius from home" was recommended. Subsequently, at the pilot's neurologist visit on October 31, 2018, the pilot reported failing his department of motor vehicle (DMV) driver's test and mentioned that he was going to try a different DMV office to get his driver's license reinstated. At the January 19, 2018, visit, the pilot told the neurologist that his driver's license had been reissued. The last office visit to the neurologist prior to the accident was on May 4, 2018. The pilot reported his disappointment with the April 2018 FAA denial to issue his medical certificate. He stated he had had an appointment with the neurosurgeon in the next 6 months to a year to replace his DBS battery. The pilot reported continued bilateral hand tremors with mild imbalance. On a physical exam, slowed movements, decreased eyeblinks, a mild wide-based gait, and left greater than right hand resting tremors were noted.

Loss of Visual Reference: Cessna 172S Skyhawk, N615JA; fatal accident occurred February 28, 2018 near Ocean City Municipal Airport (KOXB), Worcester County, Maryland

Marcson Ngwa 

 
Photo of fuel and oil slick

 Photo of various floating debris and fuel oil slick 

View of recovered outer side of crush damage pilot’s side door 

View of inner side of recovered crush damaged pilot’s door 

View of recovered outer side of crush damaged passenger door 

View of inside of crush damage passenger door 

View of recovered seatback cushion 

View of recovered small part of leading edge of wing showing crush damage 

View of recovered various fuselage skin pieces all showing crush damage 

View of recovered nose gear wheel attached to broken strut 

View of recovered main landing gear wheel 

Radar Data Flight Track N615JA
 

Marcson Ngwa 


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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Baltimore, Maryland
Cessna/Textron Aviation; Wichita, Kansas
Lycoming Engines; 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

http://registry.faa.gov/N615JA

Location: Ocean City, MD
Accident Number: ERA18LA094
Date & Time: 02/28/2018, 1930 EST
Registration: N615JA
Aircraft: CESSNA 172
Aircraft Damage: Destroyed
Defining Event: Loss of visual reference
Injuries: 2 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal

On February 28, 2018, about 1930 eastern standard time, a Cessna 172S, N615JA, was destroyed when it impacted the Atlantic Ocean about 2 miles east of Ocean City Municipal Airport (OXB), Ocean City, Maryland. The private pilot was fatally injured. The passenger was not located and was presumed fatally injured. The airplane was registered to Middle River Aviation and operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Night visual meteorological conditions prevailed, and no flight plan was filed for the flight, which departed Martin State Airport (MTN), Baltimore, Maryland, about 1753.

According to information from MTN ground control, the pilot requested visual flight rules (VFR) flight following to OXB and departed from runway 15 at MTN. The pilot contacted the departure controller after takeoff and reported climbing past 1,600 ft mean sea level (msl). The controller identified the airplane 3 miles southeast of MTN and instructed the pilot to proceed on course below the Class B airspace and to maintain VFR. At 1805, the pilot reported reaching his cruise altitude of 3,500 ft and was issued the current altimeter setting.

A review of radar track data showed the airplane approaching OXB from the northwest at an altitude around 3,500 ft msl before beginning a slow descent about 15 nautical miles (nm) northwest of OXB. The airplane continued its descent, and radar service was terminated about 3 nm northwest of OXB at an altitude of 1,350 ft msl.

The airplane was reported missing the following morning, and a search was initiated. About 1030, a search flight conducted by the flight school discovered an oil slick about 2 miles from the approach end of runway 14 at OXB.

According to the Maryland Natural Resources Police, on March 1, 2019, they were notified of an airplane that had gone missing en route to OXB. A search of the shoreline identified debris from the airplane. During the search, a fuel and oil slick was discovered that was still bubbling to the surface. They positioned their vessel around the highest concentration of fuel and oil and anchored. Divers subsequently discovered a wing and the fuselage of the airplane. Shortly thereafter, the pilot was found within the wreckage. Divers continued to search for the other victim, but the search was unsuccessful due to the deteriorating visibility and sea conditions. 

Pilot Information

Certificate: Private
Age: 28, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Unknown
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 1 Without Waivers/Limitations
Last FAA Medical Exam: 02/27/2017
Occupational Pilot: No
Last Flight Review or Equivalent: 08/24/2017
Flight Time:  (Estimated) 81 hours (Total, all aircraft), 81 hours (Total, this make and model), 3 hours (Last 90 days, all aircraft), 2 hours (Last 30 days, all aircraft) 

The pilot held a private pilot certificate with an airplane single-engine land rating that was issued on August 24, 2017. He held a Federal Aviation Administration (FAA) first-class airman medical certificate that was issued on February 2, 2017. According to the operator, the pilot had accumulated about 81 hours of total flight experience. The pilot's logbooks were not available for review, and his night flying experience could not be determined. A review of the operator's rental minimums revealed that the pilot did meet the qualifications to rent the Cessna Skyhawk 172S. In addition, the rental agreement did not specify night flying minimums. A review of the dispatch record revealed that the estimated time of departure was 1351 and the return time was estimated at 1730. 

Aircraft and Owner/Operator Information

Aircraft Make: CESSNA
Registration:N615JA 
Model/Series: 172 S
Aircraft Category: Airplane
Year of Manufacture: 2007
Amateur Built:No 
Airworthiness Certificate: Normal
Serial Number: 172S10554
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection: 01/16/2018, Annual
Certified Max Gross Wt.: 2550 lbs
Time Since Last Inspection: 68 Hours
Engines: 1 Reciprocating
Airframe Total Time: 6206.9 Hours
Engine Manufacturer: LYCOMING
ELT: C126 installed, not activated
Engine Model/Series: IO-360-L2A
Registered Owner: MIDDLE RIVER AVIATION LLC
Rated Power: 180 hp
Operator: MIDDLE RIVER AVIATION LLC
Operating Certificate(s) Held: Pilot School (141) 

The single-engine airplane was manufactured in 2007 and was powered by a Lycoming IO-360-L2A engine rated at 180 horsepower, equipped with a McCauley 2-bladed propeller. The most recent annual inspection was completed on January 16, 2018 at a tachometer time of 6,206.9 hours. A review of the maintenance logbooks revealed that the last altimeter pitot-static system and transponder test was performed on April 13, 2017; the records also indicated that all applicable Airworthiness Directives for the airframe, engine, propeller, and accessories had been completed. Fueling records revealed that the airplane was last fueled on the day of the accident with 11.08 gallons of 100LL aviation fuel. A review of the airplane's dispatch record for the accident flight revealed that there were no open discrepancies noted on the log.

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Night
Observation Facility, Elevation: OXB, 11 ft msl
Distance from Accident Site: 2 Nautical Miles
Observation Time: 1953 EST
Direction from Accident Site:90° 
Lowest Cloud Condition:  
Visibility:  10 Miles
Lowest Ceiling: Overcast / 10000 ft agl
Visibility (RVR):
Wind Speed/Gusts: 10 knots /
Turbulence Type Forecast/Actual:
Wind Direction: 230°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 29.98 inches Hg
Temperature/Dew Point: 12°C / 4°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: BALTIMORE, MD (MTN)
Type of Flight Plan Filed: None
Destination: OCEAN CITY, MD (OXB)
Type of Clearance: VFR Flight Following
Departure Time: 1753 EST
Type of Airspace: Class G 

The 1953 recorded weather at OXB, about 2 miles west of the accident site, included wind from 230° at 10 knots, 10 statute miles visibility, and overcast clouds at 10,000 ft above ground level. The temperature was 12°C, dew point 4°C, and the altimeter setting was 29.98 inches of mercury.

According to the Astronomical Applications Department at the United States Naval Observatory, the sunset was at 1752, the end of civil twilight was at 1819, and moonrise was at 1631. The phase of the moon on the day of the accident was waxing gibbous, with 98% of the moon's visible disk illuminated. 

Airport Information

Airport: OCEAN CITY MUNI (OXB)
Runway Surface Type: N/A
Airport Elevation: 11 ft
Runway Surface Condition: Water--calm
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: None 

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 1 Fatal
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Fatal
Latitude, Longitude: 38.288056, -75.091944 

The wreckage was located in the Atlantic Ocean about 2 miles off the shoreline at a depth of 50 ft. The main wreckage was not recovered. Loose debris that was found in the area of the wreckage was collected and comprised the nose gear strut and wheel, main landing gear tire, flight manuals, fire extinguisher, back seat cover, wheel chock, pilot and passenger doors, and a red tag with the airplane's registration number that read, "remove before flight." Small pieces of the fuselage were also located along the shoreline. 

Medical And Pathological Information

The Office of the Chief Medical Examiner, State of Maryland, performed an autopsy on the pilot. The cause of death was noted as drowning.

Toxicology testing performed by the FAA's Forensic Sciences Laboratory was negative for carbon monoxide, cyanide, and tested-for drugs.

Additional Information

According to the FAA Airplane Flying Handbook, FAA-H-8083-3, Chapter 10:

Night flying requires that pilots be aware of, and operate within, their abilities and limitations. Although careful planning of any flight is essential, night flying demands more attention to the details of preflight preparation and planning. Night flying is very different from day flying and demands more attention of the pilot. The most noticeable difference is the limited availability of outside visual references. Therefore, flight instruments should be used to a greater degree in controlling the airplane. Crossing large bodies of water at night in single-engine airplanes could be potentially hazardous, not only from the standpoint of landing (ditching) in the water, but also because with little or no lighting the horizon blends with the water, in which case, depth perception and orientation become difficult. During poor visibility conditions over water, the horizon will become obscure, and may result in a loss of orientation. Even on clear nights, the stars may be reflected on the water surface, which could appear as a continuous array of lights, thus making the horizon difficult to identify.

According to Advisory Circular 60-4A, "Pilot's Spatial Disorientation," tests conducted with qualified instrument pilots indicated that it can take as long as 35 seconds to establish full control by instruments after a loss of visual reference of the earth's surface. AC 60-4A further stated that surface references and the natural horizon may become obscured even though visibility may be above VFR minimums and that an inability to perceive the natural horizon or surface references is common during flights over water, at night, in sparsely populated areas, and in low-visibility conditions.

Aircraft Structural Failure: Piper PA-34-200T Seneca, N14GQ; fatal accident occurred February 19, 2018 near Minden–Tahoe Airport (KMEV), Douglas County, Nevada

Stephen Santo Filice
April 1, 1953 ~ February 19, 2018




Text Screen Shots

Accident Airplane N14GQ, a Piper PA-34-200T “Seneca II”

Accident Site, Main Wreckage

Appareo Stratus Unit

Vertical Stabilizer and Rudder

Nose Cone Section

Right Stabilator

Main Wreckage Site

Left Stabilator

Left Wing, Outboard Fuel Tank

Stabilator Trim Tab

Stabilator wreckage, viewed looking down at upper surface

Vertical stabilizer and rudder, viewed looking at left side

Left Wing, Lower Side View

Right outboard wing, lower surface

Lower Fuselage

Left outboard wing, upper surface

Forward Fuselage, Cabin Area 

Lower fuselage, viewed from right side

Right Wing, Lower Side View

Appareo Stratus Ground Track for the Flight

Left Wing

Last Five Minutes of Appareo Stratus Ground Track Near the Accident Site and Wreckage Location

Left Wing, Main Spar

Altitude and Ground Speed Based on Appareo Data

Altitude and Speed for Final Minutes Based on Appareo Data

Calculated Pitch, Bank, and Heading for Final Minutes Based on Flight Path and Selected Appareo Data

Calculated Angle-of-Attack and Load Factor for Final Minutes Based on Flight Path and Selected Appareo Data

Photo of damaged Appareo Stratus.

Google Earth overlay showing the aircraft’s departure from BFL.

Google Earth overlay showing the aircraft’s enroute portion of flight.

Google Earth overlay showing the aircraft’s final recorded tracklog points.

Plot of basic parameters from the Appareo Stratus for the entire flight.

Plot of basic parameters from the Appareo Stratus for the accident portion of the flight.

Airplane flight path with time and altitude annotated. 

Altitude, groundspeed, and rate of climb for whole flight. 

End of airplane flight path.

Altitude, groundspeed, and calibrated airspeed.

Airplane flight with airspeeds.

Altitude and vertical acceleration. 

Airplane flight path and debris field. 

Airplane flight path and fuselage, marked as N14GQ.

Airplane flight path and debris field.

Airplane flight path and ATC communications.

Airplane flight path and ATC communications.




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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Reno, Nevada
Piper Aircraft; 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

http://registry.faa.gov/N14GQ


Location: Minden, NV
Accident Number: WPR18FA091
Date & Time: 02/19/2018, 1125 PST
Registration: N14GQ
Aircraft: PIPER PA34
Aircraft Damage:Destroyed 
Defining Event: Aircraft structural failure
Injuries:1 Fatal 
Flight Conducted Under: Part 91: General Aviation - Personal 

On February 19, 2018, about 1125 Pacific standard time, a Piper PA-34-200T airplane, N14GQ, was destroyed when it impacted the ground about 4 miles northwest of Minden-Tahoe Airport (MEV), Minden, Nevada. The commercial pilot was fatally injured. The airplane was operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed, and a flight plan was not filed for the cross-country flight, which originated from Meadows Field Airport (BFL), Bakersfield, California, about 0900.

According to GPS data and a recording of communications between the pilot and air traffic control (ATC), the pilot was in contact with a controller at the Northern California Terminal Radar Approach Control.

At 1119:41, the pilot reported that the airplane was at an altitude of 14,500 ft mean sea level (msl) and about 10 miles southwest of and inbound to MEV.

At 1121:16, when the airplane was about 7 miles west of MEV, the controller asked, "how much further north are you going to go or is it for clouds?"

The controller then attempted to contact the pilot twice more, at 1122:33 and 1122:39; the pilot responded, at 1122:43, "ah, one four golf Quebec."

Three seconds later, the controller asked the pilot again, "how much further north you want to go?"

At 1122:50, the pilot asked the controller to please speak up, indicating "I can't hear you." Five seconds later, the controller repeated the question with emphasis.

At 1123:07, the pilot responded, "I'm going to orbit here to the south…south over the airport I can see it, maneuvering through a hole," which was the last transmission from the pilot.

About that time, the pilot started a wide right turn toward MEV. The GPS data showed that the airplane was at an altitude of 14,210 ft msl and on a heading of about 50°. About 24 seconds later, the airplane was at an altitude of 14,462 ft msl and was on a heading of about 122°.

Shortly afterward, as the airplane continued south, it appeared to enter a descending spiraling pattern. Specifically, GPS data showed that, at 1124:20, the airplane began a spiral turn of about 360° and descended to 13,410 ft msl; 9 seconds later, the airplane's altitude was 12,493 ft msl. At 11:24:49, the airplane began a spiral turn of about 580° and descended to an altitude of 9,750 ft msl, which was the last reliable altitude recorded. Figure 1 shows the flight track above the accident site.

Figure 1. Aerial View of the Flight Track and Wreckage Debris Field

The pilot and his son were communicating throughout the flight, via text messaging, about the weather conditions near MEV. The pilot's son described a broken cloud layer and indicated that parts of the Sierra Mountain Range were either below or obscured by clouds. The pilot asked if the clouds were broken over Lake Tahoe, to which his son replied, "yes." The pilot then stated, "is clearing up over there, might stop in Stockton." The pilot's son replied, "there's many holes over Carson Valley," and "you should be able to stay above and drop in over the valley."

A witness, who was located outside her residence about 2 miles north of the accident site, reported that she heard a loud noise that sounded similar to a "sonic boom." She looked up and saw an airplane "nose-diving down" with trailing smoke. The witness stated she did not see any flames.

PERSONNEL INFORMATION

The pilot held an airline transport pilot certificate with a rating for airplane multiengine land, commercial privileges for airplane single-engine land and single-engine sea, and private privileges for glider. The pilot was also a flight instructor with airplane single- and multiengine ratings and held an airframe and powerplant certificate (A&P) with inspection authorization. His most recent second-class medical certificate was issued September 24, 2017. On his medical certificate application, the pilot reported that he had accumulated 6,000 hours of total flight experience, of which 50 hours were in the previous 6 months.

The pilot's logbooks indicated that he had accumulated 5,945 hours of total flight experience, of which 4.9 hours were in the Piper PA-34-200T airplane during the previous 6 months. The pilot successfully completed his most recent flight review on September 24, 2017.

AIRCRAFT INFORMATION

The airplane was manufactured in 1978. It was powered by a Continental LTIO-360-EB-1B (right) and a TIO-360-EB-1B (left) engine, both of which were rated at 200 horsepower. The engines were equipped with Hartzell two-bladed, controllable-pitch propellers. According to maintenance logbooks, the airplane's last annual inspection was on August 1, 2017, with a total time of 3,948 hours, and both engines had a total time of 1,960 hours since new.

The airplane had a full-span flaps and spoiler system in accordance with the Robertson Aircraft Corporation supplemental type certificate (STC) SA154NW. This system incorporated the functions of both flaps and ailerons by removing the ailerons and changing the deployment route of the flaps. The spoilers were mounted above the flaps for roll control, and conical cambered wing tips were installed per the STC.

The airplane was equipped with a supplemental oxygen system. The maintenance logbooks indicated that the oxygen bottle was hydrostatic checked and certified on April 13, 2012, and that the bottles were filled to 1,800 psi with aviation breathing oxygen. The next hydrostatic check was due in March 2017. No evidence indicated that the check occurred at that time, and no other maintenance on the oxygen system was recorded in the maintenance logbooks.

METEOROLOGICAL INFORMATION

The nearest weather reporting station was MEV, located about 4 miles south of the accident site. The recorded weather at 1115 indicated wind from 350°at 15 knots gusting to 29 knots, visibility 10 statute miles or greater, sky clear, temperature -2°C, dew point -13°C, and an altimeter setting of 29.82 inches of mercury.

Satellite imagery taken 30 minutes before the accident revealed extensive cloud coverage over the region, as shown in figure 2, but also significant breaks in the cloud coverage, through which the ground could be seen. A pilot report about 30 minutes after the accident indicated clouds between 9,500 and 13,000 ft msl about 10 miles east of the accident site. Weather radar also showed snow showers moving through the area about the time of the accident with some light icing in the clouds.

WRECKAGE AND IMPACT INFORMATION

Initial examination of the airplane revealed that the airplane impacted the ground in an inverted, wings-level, slightly nose-down attitude. No debris was located near the main wreckage. The nose cone assembly, empennage, right wing outboard full-span flap assembly, and left outboard wing section separated from the airplane. A debris field located about 0.5 mile south of the main wreckage contained the separated airplane parts. The debris field was about 800 ft wide and 3,200 ft long and was on a 167o magnetic heading from the main wreckage to stabilator trim tab, the last airplane part found in the debris field.

The airplane wreckage was relocated to a secure facility for further examination. The examination revealed that the stabilator separated in a downward and aft direction and that the wing sections separated in a downward direction. The lower fuselage showed areas of damage and black transfer marks consistent with wing contact. There was no evidence of any pre-existing corrosion or cracking on any of the fracture surfaces. The fracture surfaces exhibited a dull, grainy appearance consistent with overstress separation. The oxygen system was found loose in the cabin area at the accident site. Examination of the system could not determine whether the pilot was using supplemental oxygen during the flight.

MEDICAL AND PATHOLOGICAL INFORMATION

The Washoe County Regional Medical Examiner's Office, Reno, Nevada, performed an autopsy on the pilot. His cause of death was multiple blunt force injuries. The autopsy revealed that the pilot had moderate coronary artery disease with 50% to 75% stenosis of the proximal and mid-segments of the left anterior descending coronary artery and 10% to 20% stenosis of the right coronary artery.

Toxicology testing performed at the Federal Aviation Administration (FAA) Forensic Sciences Laboratory identified diphenhydramine in the pilot's cavity blood (0.305 µg/mL) and liver specimens. In addition, amlodipine and atorvastatin were detected in the pilot's cavity blood and kidney specimens. No ethanol was detected.

Diphenhydramine is a sedating antihistamine used to treat allergy symptoms and aid sleep. It is available over the counter under the names Benadryl and Unisom. Diphenhydramine carries the following warning: may impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving and operating heavy machinery). Compared with other antihistamines, diphenhydramine causes marked sedation; it is also classified as a central nervous system depressant. Altered mood and impaired cognitive and psychomotor performance may also be observed. For example, during a driving simulator study, a single dose of diphenhydramine impaired driving ability more than a blood alcohol concentration of 0.1%.

The range of blood levels expected to cause effects with routine use is between 0.025 and 0.112 ug/ml. Diphenhydramine undergoes postmortem redistribution; postmortem central blood levels may thus increase by about three times.

Amlodipine is a prescription blood pressure medication. Atorvastatin is a prescription cholesterol medication. Neither medication is considered impairing.

TESTS AND RESEARCH

Airplane Performance Study

Data used in the performance study were from the airplane's Appareo Stratus PRX V2 device, which recorded GPS position and attitude and heading reference system information in its nonvolatile memory. For the accident flight, the GPS recorded data from 0926:40 to 1125:15. According to the recorded flight data, the accident flight proceeded without incident until the final minutes of the flight as the airplane approached its intended destination.

The airplane's maximum structural cruising speed (VNO) is listed in the Piper Aircraft Pilots Operating Manual as 190 mph or 165 knots calibrated airspeed. The never exceed speed (VNE) is 224 mph or 194 knots calibrated airspeed. At 11:24:37 the estimated airspeed peaks at 220 kt. The airplane exceeded VNO and VNE after completing about one revolution of the turn, at 1124:44 and 1124:49, respectively. The airplane's maximum positive flight load factor (flaps up) is listed as 3.8 G. The airplane's recorded flight vertical load increased steadily when the right turn began. The airplane's flight load reached a maximum of 3.95 G before the Appareo data became unreliable.

The unreliability of the data after the airplane exceeded the maximum load indicated that the airplane broke up at 1124:49 at an altitude of about 9,500 ft msl, (4,900 ft above ground level).

ADDITIONAL INFORMATION

Supplemental Oxygen Requirements

The flight data indicated that the airplane was operating above 12,500 ft msl for about 37 minutes, including about 15 minutes between 14,000 and 14,462 ft. According to regulations, the pilot should have been using supplemental oxygen after reaching 14,000 ft msl.

Spatial Disorientation

The FAA Civil Aeromedical Institute's publication, "Introduction to Aviation Physiology," defines spatial disorientation as a loss of proper bearings or a state of mental confusion as to position, location, or movement relative to the position of the earth. Factors contributing to spatial disorientation include changes in acceleration, flight in instrument meteorological conditions (IMC), frequent transfer between VMC and IMC, and unperceived changes in aircraft attitude.

The FAA Airplane Flying Handbook describes some hazards associated with flying when the ground or horizon are obscured. The handbook states, in part: "The vestibular sense (motion sensing by the inner ear) in particular tends to confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in the attitude of the airplane, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated; leading the pilot to believe the attitude of the airplane has changed when in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation."

These illusions include the graveyard spiral, about which, "Medical Facts for Pilots" (AM-400-03/1)," describes, in part, as the following:

The Graveyard Spiral…is associated with a return to level flight following an intentional or unintentional prolonged bank turn. For example, a pilot who enters a banking turn to the left will initially have a sensation of a turn in the same direction. If the left turn continues (~20 seconds or more), the pilot will experience the sensation that the airplane is no longer turning to the left. At this point, if the pilot attempts to level the wings this action will produce a sensation that the airplane is turning and banking in the opposite direction (to the right). If the pilot believes the illusion of a right turn (which can be very compelling), he/she will reenter the original left turn in an attempt to counteract the sensation of a right turn. Unfortunately, while this is happening, the airplane is still turning to the left and losing altitude. Pulling the control yoke/stick and applying power while turning would not be a good idea–because it would only make the left turn tighter. If the pilot fails to recognize the illusion and does not level the wings, the airplane will continue turning left and losing altitude until it impacts the ground. 

Pilot Information

Certificate: Airline Transport; Flight Instructor
Age:64, 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:No 
Instructor Rating(s): Airplane Multi-engine; Airplane Single-engine
Toxicology Performed: Yes
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam:09/24/2017 
Occupational Pilot:Yes 
Last Flight Review or Equivalent:
Flight Time: 6000 hours (Total, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: PIPER
Registration:N14GQ 
Model/Series: PA34 200T
Aircraft Category: Airplane
Year of Manufacture: 1978
Amateur Built:No 
Airworthiness Certificate: Normal
Serial Number: 34-7870455
Landing Gear Type: Retractable - Tricycle
Seats: 6
Date/Type of Last Inspection:
Certified Max Gross Wt.: 4570 lbs
Time Since Last Inspection:
Engines:2 Reciprocating 
Airframe Total Time:
Engine Manufacturer: CONT MOTOR
ELT:  
Engine Model/Series: TSIO-360-EB
Registered Owner: STUNAD LLC
Rated Power:200 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: MEV, 4729 ft msl
Distance from Accident Site: 4 Nautical Miles
Observation Time: 1915 UTC
Direction from Accident Site: 147°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 15 knots / 29 knots
Turbulence Type Forecast/Actual: / Unknown
Wind Direction: 350°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 29.82 inches Hg
Temperature/Dew Point: -2°C / -13°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: BAKERSFIELD, CA (BFL)
Type of Flight Plan Filed: None
Destination: MINDEN, NV (MEV)
Type of Clearance: Unknown
Departure Time: 0935 PST
Type of Airspace: 

Airport Information

Airport: MINDEN-TAHOE (MEV)
Runway Surface Type:
Airport Elevation: 4723 ft
Runway Surface Condition: Unknown
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: Unknown

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: 39.049722, -119.794167 (est)