Wednesday, April 22, 2020

Windshear or Thunderstorm: Cessna 337C Super Skymaster, N922EJ; fatal accident occurred March 09, 2019 in Longview, Texas

View of a separated propeller blade missing an outboard section.





View of the wreckage site.

View of the wreckage site.

View of the wreckage site.

View of the wreckage site.

View of the landing gear springs.

View of the disassembled gyro housing.

View of separated airplane parts that came to rest on tree branches.

View of a separated airplane wing leading edge section near the opening for the landing/taxi light.

View of a separated airplane wing skin section that has a fuel tank filler neck opening.

View of a separated propeller blade tip.

View of a separated propeller blade section that exhibits S-bending.

View of the vacuum pump housing that exhibits witness marks consistent with vane scoring.

View of a separated control cable that exhibits a broomstraw appearance.

View of control cables within the wreckage.

View of liberated weights.

View of a spar separation surface.

View of the separated rear propeller during recovery.

View of separated flight control stops.

View of a separated spar.

NWS Aviation Weather Centers METAR display at 1050 CST. 

View of the flight track overview. 

 View of the mid-flight segment with a NEXRAD image overlaid giving an approximate weather depiction at 0950 CST.

View of the final segment with a NEXRAD image overlaid giving an approximate weather depiction at 1050 CST. 

CAMI Toxicology Drug Information for Propranolol




Rebecca Marsh Kendrick and William Robert Kendrick

Kaycee Ann Kendrick and Coty Ray Shrum


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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Irving, Texas
Textron Aviation; Wichita, Kansas
Continental Motors; Mobile, Alabama

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

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

https://registry.faa.gov/N922EJ

Location: Longview, TX
Accident Number: CEN19FA094
Date & Time: 03/09/2019, 1047 CST
Registration: N922EJ
Aircraft: Cessna T337
Aircraft Damage: Destroyed
Defining Event: Windshear or thunderstorm
Injuries: 4 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal

Analysis 

The non-instrument-rated private pilot and three passengers departed on a cross-country flight in a multi-engine airplane, even though the pilot did not hold multiengine rating. At the time of departure, the weather was reported to be clear. However, a line of thunderstorms and high winds were along the flight route. Radar data showed that the airplane initially flew eastward and that, after entering an area of convective weather, it turned westward, likely to avoid the area of weather. The airplane then flew northeast before resuming eastward flight and entering another area of weather. The airplane then entered a series of descending spiral turns until impact. About 10 hours after the accident, a witness noted wreckage near a roadway, and the airplane was located shortly thereafter.

No preimpact anomalies were found with the airframe or engines that would have precluded normal operation of the airplane. All separations were consistent with overload.

Parts of the right wing were located between 1 and 3 nautical miles from the main wreckage, indicating that an in-flight breakup of the airplane had occurred. Radar data showed that the airplane was flying at a groundspeed of between 160 and 190 kts before it entered the spiral shaped flight track. According to the manufacturer, the airplane's maximum maneuvering speed was about 135 kts. Thus, the in-flight breakup occurred because the airplane was operating above its maximum maneuvering speed, which exceeded the design load factor of the airplane.

Various aviation weather products indicated that the airplane entered areas of significant convective weather twice. Once the airplane entered the clouds and precipitation associated with thunderstorms, the airplane was also in areas that were favorable for icing conditions. No evidence indicated that the pilot received a weather briefing on the day before or the day of the accident. If he had received a weather briefing, he could have been aware of the severe thunderstorms predicted for the flight route.

Toxicology testing showed the pilot had taken a beta blocker used in the treatment of hypertension and certain arrhythmias.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The noninstrument-rated pilot's improper decision to continue flight into convective weather conditions, which resulted in the airplane exceeding its maximum maneuvering speed and the subsequent in-flight breakup. Contributing to the accident was the pilot's inadequate preflight weather planning and his inadequate inflight weather avoidance of that weather.

Findings

Aircraft
Airspeed - Capability exceeded (Cause)
Wing structure - Capability exceeded (Cause)

Personnel issues
Decision making/judgment - Pilot (Cause)
Weather planning - Pilot (Factor)
Qualification/certification - Pilot

Environmental issues
Thunderstorm - Contributed to outcome (Cause)
Thunderstorm - Effect on operation (Factor)
Thunderstorm - Response/compensation (Factor)
Thunderstorm - Decision related to condition (Factor)

Factual Information

History of Flight

Enroute
Windshear or thunderstorm (Defining event)
Aircraft structural failure

Uncontrolled descent
Collision with terr/obj (non-CFIT)

On March 9, 2019, about 1047 central standard time, a Cessna T337C airplane, N922EJ, was destroyed during an inflight breakup and subsequent collision with trees and terrain near Longview, Texas. The private pilot and three passengers were fatally injured. The airplane was owned and operated by the pilot, who was operating it as a Title 14 Code of Federal Regulations Part 91 personal flight. Day instrument meteorological conditions with convective activity prevailed in the area about the time of the accident, and no flight plan was filed. The cross-country flight departed from the Lancaster Regional Airport (LNC), near Lancaster, Texas, about 0930, and was destined for the Lakefront Airport, near New Orleans, Louisiana.

An employee at LNC reported that the pilot and 3 other people came to the airport. The pilot came inside and bought 1 quart of oil. The employee indicated the pilot was in a good mood and that the pilot said they were flying to Louisiana. The pilot then went out and conducted a 10-minute long preflight where he put the oil in the front engine. Then they entered the airplane, started it up, and let the airplane run for about 5 minutes. The airplane was then taxied toward the south ramp out of sight. The self-serve fuel was located in that area and the employee indicated it was a long enough period of time for the pilot to service the airplane with fuel. Afterward, the airplane took off and flew away. The employee said that a severe thunderstorm went through about 0730-0830. At the time of departure, the thunderstorm had passed through and the weather present at LNC was "clear."

A witness who was near the accident site about the time of the accident reported that he was waiting for the storm to come and pass through. The wind picked up, "hard" out of the west gusting over 35 mph, and rain fell in "sheets." There was a single lighting strike. He said that the strike seemed to hit ground about 1/4 mile northwest of his house. It was the only local strike of the storm that he heard. Approximately a minute after the strike, the witness heard what sounded like an "Air Tractor" coming in for a pass. He heard no impact and saw nothing in the air. The ceiling was "no more than 100 ft." He said, "I didn't really believe at the time it could have possibly been an aircraft. Thought maybe static electricity in the clouds, or maybe a small tornado attempting to form."

A friend of the family later reported that the airplane was missing and an alert notice was issued.

A witness was driving down a road to go hunting. While driving he noticed scattered trash along a clearway above an underground pipeline in a wooded area. He looked further at the trash and saw that it was an airplane crash. He subsequently called 9-1-1. The time was about 1900. 

Pilot Information

Certificate: Private
Age: 51, Male
Airplane Rating(s): Single-engine Land
Seat Occupied:
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam:08/08/2018 
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time: (Estimated) 1200 hours (Total, all aircraft) 

According to information from the Federal Aviation Administration (FAA), the 51-year-old pilot held a private pilot certificate with an airplane single-engine land rating. The pilot's last aviation medical examination was on August 8, 2018, during which he applied for an FAA third-class medical certificate. The pilot reported on that medical certificate application that he had accumulated 1,200 hours of total flight time and no hours of flight time in the previous 6 months. He also reported taking dapagliflozin (a medication to treat diabetes), which is not permitted for use by pilots, and was subsequently issued a denial of that medical certificate. The pilot's logbook was found in the wreckage. The entry before the last entry was dated May 7, 2005. The last entry was dated August 23, 2018 and using flight time carried forward on the last page, the pilot's total logged flight time was 250.9 hours. The investigation was not able to determine how much total flight time the pilot had accumulated flying the accident airplane. 

Aircraft and Owner/Operator Information

Aircraft Make: Cessna
Registration: N922EJ
Model/Series: T337 C
Aircraft Category: Airplane
Year of Manufacture: 1968
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 337-0944
Landing Gear Type: Retractable - Tricycle
Seats: 4
Date/Type of Last Inspection:
Certified Max Gross Wt.: 4500 lbs
Time Since Last Inspection:
Engines: 2 Reciprocating
Airframe Total Time:
Engine Manufacturer: Continental
ELT:
Engine Model/Series: TSIO-360
Registered Owner: On file
Rated Power: 210 hp
Operator: On file
Operating Certificate(s) Held: None

The airplane had a total standard fuel capacity of 93 gallons (92 gallons useable) distributed between two wing fuel tanks. The airplane also had a total auxiliary fuel capacity of 38 gallons (36 gallons useable) distributed between two inboard wing fuel tanks. The airplane's maximum maneuvering speed was 155 mph (about 134.7 kts). According to the airplane owner's manual, maneuvering speed is the "maximum speed at which abrupt control travel can be used without exceeding the design load factor" of the airplane.

The previous owner of the airplane, stated that he sold the airplane to the accident pilot "in the fall" of 2018, but there was no FAA record of the purchase. The previous owner, in part, reported, "The plane performed perfectly. Total airframe time was about 1800 hrs motors were both about 600 hrs. Excellent flying airplane. Good radios and everything worked properly the last time I flew it." In addition, the previous owner stated that the airplane underwent an annual inspection shortly after the accident pilot purchased the airplane.

Meteorological Information and Flight Plan

Conditions at Accident Site: Instrument Conditions
Condition of Light:Day 
Observation Facility, Elevation: KGGG, 373 ft msl
Distance from Accident Site: 10 Nautical Miles
Observation Time: 1025 CST
Direction from Accident Site: 242°
Lowest Cloud Condition: Scattered / 2600 ft agl
Visibility:  10 Miles
Lowest Ceiling: Broken / 3200 ft agl
Visibility (RVR):
Wind Speed/Gusts: 18 knots / 28 knots
Turbulence Type Forecast/Actual: 
Wind Direction: 220°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 29.72 inches Hg
Temperature/Dew Point: 23°C / 19°C
Precipitation and Obscuration: Light - Thunderstorms - Rain
Departure Point: Lancaster, TX (LNC)
Type of Flight Plan Filed: None
Destination: New Orleans, LA (NEW)
Type of Clearance: None
Departure Time: 0930 CST
Type of Airspace:

A National Transportation Safety Board (NTSB) senior meteorologist collected factual weather data in reference to the accident flight and produced a Factual Weather Report, which is appended to the docket material associated with this investigation. The report, in part, indicated that a search of the official Automated Flight Service Station weather briefing provider Leidos Flight Service (LFS) and third-party vendors utilizing the LFS system did not have any contact with the pilot on the day before or the day of the accident.

A National Weather Service (NWS) surface analysis chart for 0900 depicted that the accident site was located ahead of a cold front and near a secondary trough of low pressure in an area favorable for the development of a multicellular line thunderstorm or squall line.

In addition, an NWS convective outlook graphic issued at 0700 depicted that a slight risk of severe thunderstorms were possible for the route of flight over eastern Texas and Louisiana, including the accident site. A convective outlook bulletin indicated that a line of strong-to-severe thunderstorms had already developed over northeast Texas ahead of the cold front and was moving to the east-northeast. The convection was identified as linear in nature with embedded line echo wave pattern and bow echoes formations and isolated supercell-type thunderstorms. The line was expected to produce damaging winds, sporadic hail, and the threat of a tornado.

The NWS issued a series of in-flight aviation weather advisories that were valid for the time surrounding the accident and the route of flight. The advisories warned of severe thunderstorms, IFR conditions, moderate turbulence, low-level wind shear, and icing.

The closest official weather reporting site was about 10 miles west of the accident location was at East Texas Regional Airport (GGG), Longview, Texas. At 1040, the recorded special weather observation at GGG included wind from 260° at 21 kts, gusting to 36 kts; visibility 2 ½ statute miles in thunderstorm, heavy rain, and mist; ceiling broken at 2,600 ft above ground level (agl), broken at 6,000 ft agl, and overcast at 9,500 ft agl; temperature 18°C; dew point 17°C; and altimeter 29.78 inches of mercury. The remarks section indicated peak wind from 250° at 36 kts occurred at 1035, lightning distant southwest through north, rain and thunderstorm began at 1025, pressure rising rapidly, hourly precipitation 0.16 inch, temperature 18.3°C, and dew point 17.2°C.

A composite radar mosaic for 1045 showed that the accident site was located on the east side of a line of intense echoes, which extended over the route of flight.

A constant pressure chart depicted a low-level jet stream with a southwesterly wind of 60 kts at an altitude that was about 5,000 ft above the accident site. Another constant pressure chart depicted a west-southwesterly wind of 55 kts at 18,000 ft.

A High-Resolution Rapid Refresh (HRRR) model sounding for 1100 was created. The sounding supported a layer of clouds between the lifted condensation level (1,055 ft) and 9,000 ft, where the relative humidity exceeded 90%. The freezing level was identified at 12,412 ft. The sounding showed an unstable environment with a potential height of convective clouds to about 38,000 ft. The potential hail size was calculated at 0.82 inch with a maximum vertical velocity of 108 kts. The sounding also supported the risk of strong storms with multicellular line- and supercell-type storms.

HRRR model parameters indicated that, at the accident airplane's cruising altitude of about 9,500 ft, the wind was from 235° at 55 kts, and the temperature was 8°C. The model parameters also indicated that, after the accident airplane climbed to an altitude of 16,200 ft when it entered the area of precipitation, the wind was from about 240° at 65 kts, and the temperature was -8°C.

The Geostationary Operational Environmental Satellite No. 16 visible image at 1037 depicted a line of convection across Texas with the accident site under an enhanced area of cumulonimbus-type clouds.

The closest NWS Weather Surveillance Radar 1988 Doppler was in Shreveport, Louisiana, which was about 35 miles east of the accident site. Base reflectivity images revealed that the accident airplane entered an area of heavy-to-intense echoes by 1038 with hail to 0.67 inch indicated.

Lightning data, obtained from archive data from Earth Networks, showed that, between 1030 and 1050, there were 836 total lightning flashes within about a 40-mile radius of the accident site. There were 53 cloud-to-ground lightning strikes and 783 in-cloud lightning flashes.

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: 32.461111, -94.539167 (est) 

The main wreckage, which consisted of the fragmented fuselage, empennage, inboard wings sections, left outboard wing section, and both engines, was found embedded about 6 to 8 ft below grade in wooded terrain about 62° and 10 nautical miles from GGG. One fuel tank was found fragmented near the main wreckage in the woods and one fuel tank was found in a clearway for an underground pipeline near the main wreckage. Highly fragmented sections of the fuselage, wings, and empennage were found in the woods widely distributed around the main wreckage.

A backhoe was used to raise the wreckage from below grade. The rear propeller blades were attached to their hub and that hub remained attached to its propeller flange. However, the flange was separated from its engine crankshaft just forward of its flange. One blade exhibited leading edge nicks and the other blade exhibited S-shaped bending. The front propeller hub remained attached to its engine. However, the hub's blades did not remain attached. One inboard section of a front propeller blade was identified on site, and one outboard section of a front propeller blade was identified on site. Those sections exhibited separations in overload and chordwise abrasion. The outboard section exhibited S-shaped bending. A disassembled instrument gyro exhibited rotational scoring on its rotor and rotor housing. The recovered main accident site wreckage was subsequently taken to a storage facility.

An NTSB aerospace engineer and a safety investigator from the airplane manufacturer examined the recovered wreckage at a storage facility in Marshall, Texas, on June 17-18, 2019. The examination revealed that the wreckage from the main site was fragmented and exhibited fore-aft crushing with an accordion style deformation pattern. Three corners of the airplane, the front/fuselage, left wing, and empennage were identified in the wreckage from the main site.

The airplane manufacturer defines the location of parts of the airplane longitudinally and laterally using station locations and vertically using waterline locations measured in inches from a datum. The wing station (WS) datum is located at the centerline of the airplane and distances on the left and right sides are measured outboard to the ends of the wings.

A right outboard wing section was recovered about 72° and 1 nautical mile from the main wreckage. This outboard wing section was mostly intact from the outboard end rib inboard about 72 inches. Its aileron was mostly intact and attached. The right aileron rod end was attached to the aileron but fractured from its push-pull tube. The right aileron bellcrank control quadrant was not present in the right wing. However, the wing section exhibited damage in the area of the quadrant consistent with the quadrant being torn out. The right rear spar was fractured near WS 159. The right forward spar upper cap was fractured near WS 112 and it exhibited upward deformation at the fracture. The right forward spar lower cap was fractured near WS 150 and no deformation was observed at the fracture. The right forward spar was twisted clockwise as viewed looking outboard. The right spar fractures had angular features and a dull, grainy appearance consistent with overstress separation.

A right outboard flap segment was recovered about 59° and 3 nautical miles from the main wreckage. The flap segment was about 50 inches long and it was mostly intact from leading edge to trailing edge. However, it exhibited buckling damage on its upper and lower skins.

A right outboard leading-edge segment was recovered about 72° and 1.7 nautical miles from the main wreckage. This section spanned from WS 110 to WS 133. Its landing gear inspection mirror remained intact. A portion of the landing light housing remained attached to the leading edge. However, no lights remained attached.

All separations in control cables exhibited a broom-straw appearance consistent with overload. All observed skin and structure separations exhibited an appearance consistent with overload. There was no evidence of corrosion or other pre-existing conditions on any of the primary structure examined.

A safety investigator from the engine manufacturer under NTSB supervision also examined the recovered engines at the storage facility. The front engine data plate was not present and was not located during the airplane recovery. However, its configuration was consistent with a Continental TSIO-360-A engine. The rear engine was a TSIO-360-A engine with serial number 184247-8-A.

The front engine exhibited several holes in its crankcase exposing the inside of the engine. No pre-impact failures were noted to its crankshaft or connecting rods. The No. 5 and 6 cylinder heads were impact separated and not observed. The No. 5 cylinder barrel had separated from the crankcase and the piston was lodged in the cylinder barrel, still connected to the crankshaft by the connecting rod. All of the remaining cylinder heads exhibited varying amounts of impact damage. The fuel pump, propeller governor, fuel manifold valve, magnetos, induction and exhaust systems were not observed with the engine.

The rear engine exhibited several crankcase breaches and no pre-impact failures were noted to its crankshaft or connecting rods. The No. 1 and 2 cylinder heads exhibited impact damage. The top spark plugs from No. 4, 5, and 6 cylinders were removed and exhibited light grey combustion deposits and the electrodes were worn out-normal when compared to the Champion Check a Plug chart. The fuel manifold valve remained partially attached to the engine. The fuel manifold valve was removed and disassembled with no anomalies noted. The fuel pump remained attached to the engine and exhibited impact damage. The fuel pump was removed, and the fuel pump drive was intact. The fuel pump did not turn and the pump was disassembled. Rust was noted in the fuel pumps rotor. No other anomalies were noted to the internal parts of the fuel pump. The throttle body remained partially attached and exhibited impact damage. The throttle plate turned freely by hand from stop to stop. The rear engine turbo charger remained partially attached to the engine mount and exhibited impact damage. The compressor scroll exhibited rotational scoring and the compressor blades were bent opposite of rotation.

Loose pieces

The following parts were located throughout the aircraft wreckage:
A starter with a portion of a starter adaptor that exhibited impact damage.
A turbo charger was located that exhibited severe impact damage. The compressor scroll was not observed, and the compressor blades were heavily damaged.

A throttle body that was impact damaged and packed with mud.
One damaged magneto was located loose in the wreckage. The magneto drive did not turn by hand. The magneto was disassembled, and no pre-impact anomalies were noted.

Rear Propeller

The rear propeller was separated from the engine. The crankshaft propeller flange was fractured from the engine and remained attached to the rear propeller hub. Both blades remained attached to the hub and both exhibited forward bending throughout their entire span. Both blades exhibited chordwise scratching and leading-edge polishing. One blade exhibited two nicks in the trailing edge.

Front propeller

The front propeller was separated from the engine. The propeller hub was not observed and both blades were loose. One blade exhibited S bending, chordwise scratches and leading-edge polishing. The blade was fractured into two pieces about midspan. The other propeller blade exhibited leading edge polishing and chordwise scratches. It was fractured about midspan and the outer piece of the propeller blade was not recovered.

Both engines did not exhibit any anomalies or damage that could not be associated with the ground impact.

MEDICAL AND PATHOLOGICAL INFORMATION

Forensic Medical of Texas, P.A., Tyler, Texas, performed an autopsy of the pilot. The pilot's cause of death was severe blunt force injuries.

Toxicology testing performed at the FAA Forensic Sciences Laboratory identified propranolol (a beta-blocker used to treat hypertension and certain arrhythmias) in the pilot's muscle specimens.

Communications

No records of air traffic control communication were found in reference to N922EJ. 

Tests And Research

An NTSB senior air traffic investigator examined FAA data to include radar data and a video playback of a segment of the flight's track. The video is appended to the docket material associated with this investigation. The radar data was plotted to show the airplane's route of flight. The data showed the airplane east of LNC, traveling eastward. The airplane entered an area of weather and turned back westward out of the area of weather. The data further showed the airplane subsequently traveling eastward and entering another area of weather. The video showed the airplane was flying between 160 to 190 kts before it started a spiral shaped track. The radar data and video showed that the airplane descended during the spiral shaped flight track. The spiral shaped flight track is near the accident site. 

Additional Information

In August of 2018, the pilot contacted a flight instructor at a fixed base operator (FBO) for a flight review in a Cessna 182. The pilot had gone through an online refresher course for his ground knowledge. The pilot advised that it had been about 4-5 years since he had last flown. He had purchased a Cessna 337 and intended to fly to southern Texas in it. The flight instructor advised the pilot that he would have to coordinate multi-engine training with a multi engine instructor to fly his Cessna 337. The instructor then developed a 2-hour block in the classroom for the flight review around preflight planning, weather products and preparation, as well as cross-country planning for a flight to southern Texas. The flight portion of the flight review in a Cessna 182 included slow flight, steep turns, power on and off stalls before returning to the airport for performance landings. Much of the flight time was used during maneuvers and repeated attempts. The pilot advised the instructor, "I don't think I'm comfortable enough to fly this airplane to my ranch this weekend. I felt behind the plane and think more time is needed." The instructor agreed and encouraged the pilot that in time he would get back to a state of comfortability and proficiency in the aircraft. The instructor did not complete nor endorse the pilot for the flight review or checkout in the 182.

In October 2018, the chief flight instructor at the FBO was contacted by the pilot for training in his Cessna 337. He advised the pilot that he had no 337 experience, but the pilot had the instructor fill out his insurance documents regardless. The insurance company replied that the chief instructor would be covered as a flight instructor for the pilot in his C337. The chief instructor flew about 2 hours in the 337. The pilot sat in the right seat and the chief instructor sat in the left seat during the 2 hour flight. However, no instruction was given to the pilot. The chief instructor reported that the airplane had a paint job that appeared to be done by spray paint can and the avionics were old. The powerplants operated nominally within parameters. He indicated it appeared that the airplane had not been updated but was airworthy. All primary systems operated nominally. The chief instructor provided the pilot an hour of instruction in a flight training device set up as a conventional multiengine aircraft. The airplane was returned to the hangar and the chief instructor never heard back from the pilot.

Collision During Landing: Grumman American AA-5B Tiger, N314JG; accident occurred April 21, 2020 in Bloomingdale, Chatham County, Georgia







Aviation Accident Final Report - National Transportation Safety Board

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Atlanta, Georgia 

Investigation Docket - National Transportation Safety Board:


Location: Bloomingdale, Georgia 
Accident Number: ERA20CA155
Date & Time: April 21, 2020, 13:45 Local 
Registration: N314JG
Aircraft: Grumman AA5
Aircraft Damage: Substantial
Defining Event: Collision during takeoff/land
Injuries: 1 Serious
Flight Conducted Under: Part 91: General aviation - Personal

Analysis

According to the pilot, he was returning to his home airport. The accident occurred during the landing attempt; the pilot could not recall the approach or accident sequence due to his injuries. According to a witness who lived near the airport, he heard the airplane and saw it fly over the midfield before it entered the left downwind leg of the traffic pattern for runway 13. He noted that the engine power was "pulled back." A few minutes later, the witness heard an impact. The airplane impacted trees and terrain on the left side of the runway and came to rest about 1,000 ft past the runway's approach end. The airplane sustained substantial damage to the fuselage, both wings, and the empennage. A Federal Aviation Administration inspector who examined the wreckage stated that he found no preaccident anomalies with the airplane that would have precluded normal operation. According to a report from an airport 10 miles southeast of the accident site, the wind was gusting to 18 knots.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's failure to maintain airplane control during landing with a gusting quartering tailwind.

Findings

Personnel issues Aircraft control - Pilot
Aircraft (general) - Not attained/maintained
Environmental issues Gusts - Effect on operation
Environmental issues Crosswind - Effect on operation

Factual Information

History of Flight

Approach-VFR pattern final Other weather encounter
Approach-VFR pattern final Loss of control in flight
Approach-VFR pattern final Collision during takeoff/land (Defining event)

Pilot Information

Certificate: Private 
Age: 58, Male
Airplane Rating(s): Single-engine land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: Unknown
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None 
Toxicology Performed: No
Medical Certification: Class 3 With waivers/limitations 
Last FAA Medical Exam: November 26, 2019
Occupational Pilot: No 
Last Flight Review or Equivalent: December 28, 2019
Flight Time: 1035 hours (Total, all aircraft), 1034 hours (Total, this make and model), 1012 hours (Pilot In Command, all aircraft), 6 hours (Last 90 days, all aircraft), 3 hours (Last 30 days, all aircraft), 1 hours (Last 24 hours, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: Grumman
Registration: N314JG
Model/Series: AA5 B 
Aircraft Category: Airplane
Year of Manufacture: 1975
Amateur Built: No
Airworthiness Certificate: Normal 
Serial Number: AA5B-0083
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection: November 13, 2019 Annual
Certified Max Gross Wt.: 2401 lbs
Time Since Last Inspection: 
Engines: 1 Reciprocating
Airframe Total Time: 2297.61 Hrs at time of accident
Engine Manufacturer: Lycoming
ELT: Installed 
Engine Model/Series: O-360-A4K
Registered Owner: 
Rated Power: 180 Horsepower
Operator: On file
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual (VMC)
Condition of Light: Day
Observation Facility, Elevation: SAV,51 ft msl 
Distance from Accident Site: 10 Nautical Miles
Observation Time: 13:53 Local
Direction from Accident Site: 101°
Lowest Cloud Condition: Few / 25000 ft AGL
Visibility 10 miles
Lowest Ceiling:
Visibility (RVR):
Wind Speed/Gusts: 11 knots / 18 knots 
Turbulence Type Forecast/Actual:  /
Wind Direction: 290° 
Turbulence Severity Forecast/Actual:  /
Altimeter Setting: 29.88 inches Hg 
Temperature/Dew Point: 27°C / 7°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Statesboro, GA (TBR)
Type of Flight Plan Filed: None
Destination: Bloomingdale, GA (GA35) 
Type of Clearance: None
Departure Time: 12:30 Local 
Type of Airspace: Class G

Airport Information

Airport: Cypress Lakes GA35 
Runway Surface Type: Grass/turf
Airport Elevation: 30 ft msl 
Runway Surface Condition:  Dry; Vegetation
Runway Used: 13
IFR Approach: None
Runway Length/Width: 2700 ft / 100 ft 
VFR Approach/Landing: Traffic pattern

Wreckage and Impact Information

Crew Injuries: 1 Serious
Aircraft Damage: Substantial
Passenger Injuries:
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Serious
Latitude, Longitude: 32.159721,-81.39833(est)

Air Tractor AT-602, N653LA: Accident occurred April 21, 2020 in Mamou -and- Accident occurred April 21, 2017 in Vidrine - Louisiana







Aviation Accident Final Report - National Transportation Safety Board 

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Baton Rouge, Louisiana

Investigation Docket - National Transportation Safety Board:


Location: Mamou, LA
Accident Number: CEN20CA153
Date & Time: 04/21/2020, 1800 CDT
Registration: N653LA
Aircraft: Air Tractor AT 602
Aircraft Damage: Substantial
Defining Event: Collision during takeoff/land
Injuries: 1 None
Flight Conducted Under: Part 137: Agricultural 

Analysis

The pilot reported that the turf airstrip had a "sunken area," which created a "ramp." During takeoff, the airplane encountered this portion of the airstrip and became "airborne prematurely." The airplane subsequently settled into ground effect; however, the left wing impacted a small tree near the end of the runway, and the airplane then pitched "downward and left," and the airplane was unable to maintain altitude. The airplane impacted a field off the end of the runway. The airplane sustained substantial damage to the wings and fuselage. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The airplane's encounter with a sunken area during takeoff from a turf runway, which resulted in the airplane becoming prematurely airborne and impacting a tree and then terrain.

Findings

Environmental issues (general) - Effect on operation
Environmental issues Tree(s) - Effect on operation

Factual Information

History of Flight

Takeoff Collision during takeoff/land (Defining event)
Takeoff Loss of control in flight

Pilot Information

Certificate: Commercial
Age: 45, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Single
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): None
Second Pilot Present: No 
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 2 Without Waivers/Limitations
Last FAA Medical Exam: 02/04/2020
Occupational Pilot: Yes
Last Flight Review or Equivalent: 01/08/2019
Flight Time:  7700 hours (Total, all aircraft), 756 hours (Total, this make and model), 7618 hours (Pilot In Command, all aircraft), 125 hours (Last 90 days, all aircraft), 80 hours (Last 30 days, all aircraft), 0 hours (Last 24 hours, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: Air Tractor
Registration: N653LA
Model/Series: AT 602 No Series
Aircraft Category:Airplane 
Year of Manufacture: 2002
Amateur Built: No
Airworthiness Certificate: Restricted
Serial Number: 602-0653
Landing Gear Type: Tailwheel
Seats: 1
Date/Type of Last Inspection: 04/17/2020, 100 Hour
Certified Max Gross Wt.: 12500 lbs
Time Since Last Inspection: 10 Hours
Engines: 1 Turbo Prop
Airframe Total Time: 9550 Hours at time of accident
Engine Manufacturer: Pratt & Whitney Canada
ELT: Not installed
Engine Model/Series: PT6A-60AG
Registered Owner: Central Farmers Cooperative
Rated Power:1050 hp 
Operator: Central Farmers Cooperative
Operating Certificate(s) Held: Agricultural Aircraft (137)
Operator Does Business As: Central Farmers Flying Service
Operator Designator Code: SIRG

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: ACP, 107 ft msl
Distance from Accident Site: 15 Nautical Miles
Observation Time: 1755 CDT
Direction from Accident Site: 282°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 5 knots /
Turbulence Type Forecast/Actual:
Wind Direction: 130°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 29.96 inches Hg
Temperature/Dew Point: 28°C / 15°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Mamou, LA (PVT)
Type of Flight Plan Filed: None
Destination: Mamou, LA (PVT)
Type of Clearance: None
Departure Time: 1810 CDT
Type of Airspace: Class G

Airport Information

Airport: Deculus Satellite Airstrip (N/A)
Runway Surface Type: Grass/turf
Airport Elevation: 65 ft
Runway Surface Condition: Dry; Rough
Runway Used: 18
IFR Approach:None 
Runway Length/Width: 3550 ft / 70 ft
VFR Approach/Landing: None

Wreckage and Impact Information

Crew Injuries: 1 None
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 None
Latitude, Longitude:  30.589444, -92.427778

Fuel flowmeter

Flowmeter

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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Baton Rouge, Louisiana
Air Tractor, Inc; Olney, Texas 

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

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

Location: Vidrine, LA
Accident Number: CEN17LA165
Date & Time: 04/21/2017, 1300 CDT
Registration: N653LA
Aircraft: AIR TRACTOR INC AT 602
Aircraft Damage: Substantial
Defining Event: Loss of engine power (total)
Injuries: 1 None
Flight Conducted Under: Part 137: Agricultural

Analysis 

The pilot was conducting agricultural spray operations in a turbine-powered airplane. During turns, he noticed that the fuel pressure varied between 19 and 20 lbs per square inch, but otherwise it appeared normal. During a subsequent turn, the engine lost power. The pilot turned on the fuel boost pump and engine ignitor, but the engine did not respond, so he conducted a force landing to a rice field. During the landing, the airplane impacted several levees, and the main landing gear were torn off; the airplane subsequently came to a stop on its belly.

The pilot reported that he looked into each wing fuel tank and that fuel was visible in each tank. Two witnesses also looked into each tank and reported seeing between about 3 and 4 inches of fuel in each tank. They added that the tanks were breached and leaking fuel. The responding Federal Aviation Administration inspector reported that the tanks were empty when he arrived on scene, but it appeared that the tanks had been breached, and fuel had leaked onto the ground.

The airplane was disassembled and transported to a repair facility. An examination of the airplane revealed fuel in the airframe filter and engine high-pressure canisters. About 1 quart of fuel was drained from the header tank. No contaminants were found in the fuel.

The fuel flow meter displayed 52.1 gallons for fuel remaining and 157 gallons used. The flow meter does not have a fuel level sensing capability but subtracts the fuel used from what the user (pilot) input into the meter. The flow meter was programmed to 209 gallons at the last refueling or instrument reset. Given the pilot may have reset the meter during the last refuel, the meter would have registered a full fuel load even if the airplane had not received a full fuel load; thus, the 52.1 gallons remaining would not have been accurate.

The engine was separated from the airframe and sent to overhaul/repair facility. The engine was placed in a test cell and started and ran with no anomalies noted. The reason for the loss of power was not determined. 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The total loss of engine power for reasons that could not be determined because an examination of the engine and a test run did not reveal any mechanical malfunctions or failures that would have precluded normal operation.

Findings

Not determined
Not determined - Unknown/Not determined (Cause)

Factual Information 

On April 21, 2017, about 1300 central daylight time, an Air Tractor AT602 agricultural airplane, N653LA, conducted a forced landing near Vidrine, Louisiana. The pilot was not injured and the airplane was substantially damaged during the landing. The airplane was registered to and operated by Central Farmers Cooperative dba Central Farmers Flying Service under the provisions of 14 Code of Federal Regulations Part 137 as an aerial application flight. Visual meteorological conditions prevailed at the time.

The pilot reported that he was conducting spray operations, adding that during turns, the fuel pressure would vary from 19 to 20 psi. Even though he hadn't seen the variance before, he thought the it appeared normal. Then during a turn, the engine lost power. He turned on the [fuel] boost pump, and engine ignitor, but the engine did not restart. The pilot then conducted a forced landing in a rice field.

During the landing, the airplane impacted several levees. The airplane's main landing gear were torn off during the landing, and the airplane came to a stop on its belly. The pilot then looked in the fuel tanks and reported that fuel was visible in both left and right fuel tanks. Two other people who were assisting the pilot, who arrived on scene, reported there was 3 to 4 inches of fuel in each tank, and fuel was leaking from the tanks.

The responding Federal Aviation Administration (FAA) inspector noted substantial damage to the airplane's left and right wings. He added that the fuel tanks were empty when he arrived, but it appeared that both tanks had been breached and leaked their contents on the ground.

The airplane was partially dismantled, including removal of the wings, for recovery and then transported to a repair facility. An examination was then conducted by the NTSB Investigator-in-Charge and a technical representative from the airframe manufacturer.

The engine fuel lines, including the Py line, were checked and there were no apparent damage or leaks in the lines. The airframe fuel filter, located on the firewall, was opened; the filter/canister was full of fuel. The engine high pressure fuel pump filter bowl was opened, and the fuel level was about one inch below the top; no debris or contaminates were found. Approximately 1 quart of fuel was drained from the airplane's fuel header tank; the fuel appeared clean.

Without electrical power, (and the wings removed from the airplane) the left and right fuel gauges read about 1/16 inch and 1/8 inch above empty, respectively. Electrical power was applied to the airplane, and a self-test was successful on the Shadin fuel flowmeter. The unit displayed 52.1 for fuel remaining, and 157 for fuel used. The airplane was equipped with a 210-gallon fuel system. The flowmeter does not have a fuel level sensing capability, but subtracts fuel from what the user (pilot) input into the meter. The flowmeter was programed to 209, at the last refueling or instrument reset.

The engine was separated from the airframe and sent to overhaul/repair facility. Prior to overhaul, the engine was placed in an engine test cell. Under the supervision of an FAA inspector, an engine test run was conducted. The engine started and ran, with no abnormalities noted.

A reason for the loss of engine power was not found. 

History of Flight

Maneuvering-low-alt flying
Loss of engine power (total) (Defining event)

Emergency descent
Collision with terr/obj (non-CFIT) 

Pilot Information

Certificate: Commercial
Age: 58
Airplane Rating(s): Single-engine Land
Seat Occupied: Single
Other Aircraft Rating(s): None
Restraint Used: 4-point
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 2
Last FAA Medical Exam: 04/19/2016
Occupational Pilot: Yes
Last Flight Review or Equivalent: 12/28/2015
Flight Time:  9654 hours (Total, all aircraft), 300 hours (Total, this make and model), 200 hours (Last 90 days, all aircraft), 200 hours (Last 30 days, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Manufacturer: AIR TRACTOR INC
Registration: N653LA
Model/Series: AT 602 NO SERIES
Aircraft Category: Airplane
Year of Manufacture: 2002
Amateur Built: No
Airworthiness Certificate: Restricted
Serial Number: 602-0653
Landing Gear Type: Tailwheel
Seats: 1
Date/Type of Last Inspection: 03/30/2017, Continuous Airworthiness
Certified Max Gross Wt.:
Time Since Last Inspection:
Engines:  Turbo Prop
Airframe Total Time: 8636.3 Hours at time of accident
Engine Manufacturer: P&W
ELT: Not installed
Engine Model/Series: PT6A
Registered Owner: CENTRAL FARMERS FLYING SERVICE
Rated Power:
Operator: CENTRAL FARMERS FLYING SERVICE
Operating Certificate(s) Held: Agricultural Aircraft (137) 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KACP
Observation Time: 1255 CDT
Distance from Accident Site: 15 Nautical Miles
Direction from Accident Site: 270°
Lowest Cloud Condition: Scattered / 3400 ft agl
Temperature/Dew Point: 28°C / 20°C
Lowest Ceiling: Broken / 4000 ft agl
Visibility:  10 Miles
Wind Speed/Gusts, Direction: 7 knots, Variable
Visibility (RVR): 
Altimeter Setting: 29.93 inches Hg
Visibility (RVV):
Precipitation and Obscuration: No Precipitation
Departure Point: Vidrine, LA (LA25)
Type of Flight Plan Filed: None
Destination: Vidrine, LA (LA25)
Type of Clearance: None
Departure Time:
Type of Airspace:

Wreckage and Impact Information

Crew Injuries: 1 None
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 None
Latitude, Longitude:  30.693889, -92.403333 (est)