Sunday, December 20, 2020

Lawsuit Filed: Bell UH-1H Iroquois, N658H; fatal accident occurred January 17, 2018 in Raton, Colfax County, New Mexico

SANTA FE – The sole survivor of a fatal helicopter crash that killed five people is suing the estates of the pilot and the billionaire who owned the aircraft, claiming the billionaire’s “James Bond” lifestyle contributed to the crash that killed her father. 

Andra Cobb and her mother, Martha Cobb, both of Montgomery County in Texas, filed a lawsuit against Sapphire Aviation, and the estates of pilot Jamie Dodd and helicopter-owner Charles Burnett for the crash that killed five people near Raton in January 2018.

Andra Cobb was in a long-term romantic relationship with Burnett, who she met through her father, Paul Cobb, according to the complaint.

The crash victims included Paul Cobb, Zimbabwe politician Roy Bennett, his wife, Heather Bennett, Dodd and Burnett.

The lawsuit filed December 11th in 1st Judicial District Court in Santa Fe seeks a jury trial and damages for the wrongful death of Paul Cobb and permanent injuries to Andra Cobb as a result of the crash.

Michael Lyons, co-counsel for Martha, David and Paul Cobb, said the family will never get over the tragedy.

“This shouldn’t have happened,” Lyons said in a phone interview. “This is a terrible tragedy and, fortunately, in our system of government in this country, you have a right to have a jury of your peers decide disputes like this.”

Lyons said he has no expectation for resolving the case through a settlement and is readying the case for trial.

Andra Cobb is being represented by different attorneys.

According to the lawsuit, “billionaire and international playboy” Burnett was taking the group to his ranch in the northern New Mexico community of Folsom for a party. Burnett allegedly ordered Dodd to fly the group from the Raton airport to his ranch after dark. The lawsuit states Burnett was “accustomed to issuing orders and having them followed,” and the ranch was used to host “elaborate parties and fuel his insatiable need for adventure.”

The group ultimately crashed 11 miles from the Raton airport on Blosser Gap Mesa. It took emergency responders two hours to reach the crash scene due to the remote location.

Blood tests from Dodd, who was flying the Vietnam-era “Huey” helicopter, showed he had diphenhydramine, a generic Benadryl, in his system at the time of the crash. A common side effect of Benadryl is drowsiness, according to the manufacturer.

The National Transportation Safety Board listed the cause of the crash as Dodd’s failure to fly at an adequate altitude above the mountainous terrain at night.

Dodd never flew the Huey from Raton to the ranch before in either night or day conditions, the lawsuit said.

The lawsuit reported some of Dodd’s last words to be “it was my fault. I flew into the terrain … this is all my fault.”


Jamie Coleman Dodd

   
Paul Cobb

Charles Ryland Burnett III

 Roy Bennett and his wife Heather.

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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Albuquerque, New Mexico
Honeywell Aerospace; Phoenix, Arizona
Rotorcraft Development Corporation; Hamilton, Montana
Air Accidents Investigation Branch, UK; FN

Investigation Docket - National Transportation Safety Board:


Location: Raton, NM
Accident Number: CEN18FA078
Date & Time: 01/17/2018, 1800 MST
Registration: N658H
Aircraft: BELL UH-1H
Aircraft Damage: Destroyed
Defining Event: Controlled flight into terr/obj (CFIT)
Injuries: 5 Fatal, 1 Serious
Flight Conducted Under: Part 91: General Aviation - Personal 

Analysis 

The commercial pilot, a pilot rated passenger and four passengers departed in the helicopter on a cross-country flight in dark night visual meteorological conditions. According to the sole surviving passenger, the flight proceeded normally until it impacted the ground in level flight and came to rest inverted.

The pilot initially survived the accident but succumbed to his injuries en route to the hospital. A witness who spoke to the pilot before he was transported from the accident site reported that the pilot said that he had flown into terrain.

Overhead imagery revealed that the area surrounding the accident site comprised unpopulated ranchland grass and sparse, low brush. The imagery showed a reduced amount of visual terrain features in the area of the accident site during night conditions and there were no sources of ground lighting or illumination in the vicinity. The pilot's familiarity with the route of flight could not be determined.

The wreckage was located on a nearly-level mesa that rose about 100 ft above the surrounding mountainous terrain. A postaccident examination did not reveal any preimpact anomalies that would have precluded normal operation of the helicopter, and ground scars at the site were consistent with impact in a level attitude.

Toxicology testing indicated a therapeutic level of diphenhydramine in the pilot's blood at the time of the accident, which likely impaired him to some degree; however, it could not be determined if psychomotor slowing from the diphenhydramine contributed to his inability to recognize and/or avoid the terrain.

FAA Advisory Circular (AC) 61-134, General Aviation Controlled Flight into Terrain Awareness, defines controlled flight into terrain (CFIT) as when an airworthy aircraft is flown, under the control of a qualified pilot, into terrain (water or obstacles) with inadequate awareness on the part of the pilot of the impending collision. Professional aviation articles on CFIT state that during night conditions where the height above terrain may be misperceived by a pilot, controlled flight into terrain can occur, even to experienced pilots.

Given the lack of mechanical anomalies and the level impact attitude of the helicopter, it is likely that the pilot failed to maintain adequate altitude during cruise flight and subsequently impacted rising terrain. 

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 adequate altitude above mountainous terrain during cruise flight in dark night conditions, which resulted in controlled flight into terrain.

Findings

Rotorcraft 

Personnel issues
Aircraft control - Pilot (Cause)
Flight planning/navigation - Pilot

Environmental issues
Terrain - Effect on personnel (Cause)
Dark - Contributed to outcome (Cause)

Factual Information

History of Flight

Enroute-cruise
Controlled flight into terr/obj (CFIT) (Defining event) 

On January 17, 2018, about 1800 mountain standard time, a Bell UH-1H helicopter, N658H, impacted terrain near Raton, New Mexico. The helicopter was subsequently consumed by a postimpact fire. The commercial pilot, a pilot-rated passenger, and three other passengers were fatally injured. One passenger sustained serious injuries. The helicopter was destroyed. The helicopter was registered to and operated by Sapphire Aviation LLC as a Title 14 Code of Federal Regulations Part 91 personal flight. Night visual meteorological conditions prevailed in the area about the time of the accident, and no flight plan was filed. The flight originated from the Raton Municipal Airport/Crews Field (RTN), near Raton, New Mexico, about 1750 and was destined for Folsom, New Mexico.

According to a statement taken by Federal Aviation Administration (FAA) Inspectors, the surviving passenger stated that the group of passengers boarded a private airplane in Houston, Texas and the airplane flew them to Raton, New Mexico. They subsequently boarded a company helicopter. The purpose of the helicopter flight was to take the group to personal function in Folsom, New Mexico. The passenger reported that the takeoff was normal. As they were flying east, the sun had gone down, and the stars were very bright. The passenger reported no turbulence during the flight. There were no unusual noises, no observed warning lights in the cockpit, and the pilot and copilot were calm; everything appeared normal. The passenger recalled that they were in level flight and when she heard a big bang as the helicopter hit the ground. After ground contact, the helicopter rolled forward coming to a stop upside down. The passenger was hanging from the seat belt, the door was not present, and jet fuel was pouring on her. She released her seat belt and egressed the helicopter. The helicopter was on fire and subsequent explosions followed. The passenger called 9-1-1 and waited for emergency responders.

According to a first responder, he arrived at the accident site about 2000 and paramedics arrived there about 2015.

The pilot initially survived the accident but succumbed to his injuries en route to a hospital. A witness stated that he was with the pilot before he was loaded in the rescue helicopter and asked the pilot what happened. The pilot replied that the accident was his fault and that he had flown into terrain.

Pilot Information

Certificate: Commercial
Age: 57, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s): Helicopter
Restraint Used: Unknown
Instrument Rating(s): Helicopter
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 12/07/2017
Occupational Pilot: Yes
Last Flight Review or Equivalent:
Flight Time: (Estimated) 6416 hours (Total, all aircraft) 

Pilot-Rated Passenger Information

Certificate: Commercial
Age: 67, Male
Airplane Rating(s): None
Seat Occupied: Left
Other Aircraft Rating(s): Helicopter
Restraint Used: Unknown
Instrument Rating(s):
Second Pilot Present: Yes
Instructor Rating(s):
Toxicology Performed: Yes
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 12/11/2017
Occupational Pilot:
Last Flight Review or Equivalent:
Flight Time: (Estimated) 3140 hours (Total, all aircraft) 

The pilot held a commercial pilot certificate with airplane single-engine land, rotorcraft-helicopter, and instrument helicopter ratings. He held an FAA second-class medical certificate issued on December 7, 2017. The pilot reported on the application for his medical certificate that he had accumulated 6,416 hours of total flight time and 44 hours in the six months before the examination. His medical certificate was issued with the limitation that he must wear corrective lenses for distant, have glasses for near vision. The pilot reported on an insurance questionnaire that he had accumulated 2,065 hours of total flight time in UH-1 helicopters.

The pilot rated passenger held a commercial pilot certificate with a rotorcraft-helicopter rating. He held a second-class medical certificate issued on December 11, 2017. The pilot-rated passenger reported on the application for his medical certificate that he had accumulated 3,140 hours of total flight time and 30 hours in the six months before the examination. His medical certificate was issued with the limitations that he must wear corrective lenses, and that the certificate was not valid for any class after December 31, 2018. The pilot-rated passenger reported on an insurance questionnaire that he had accumulated 120 hours of total flight time in UH-1 helicopters.

Aircraft and Owner/Operator Information

Aircraft Make: BELL
Registration: N658H
Model/Series: UH-1H
Aircraft Category: Helicopter
Year of Manufacture: 2007
Amateur Built: No
Airworthiness Certificate: Restricted
Serial Number: 67-17658
Landing Gear Type: Skid;
Seats:
Date/Type of Last Inspection:
Certified Max Gross Wt.: 9500 lbs
Time Since Last Inspection:
Engines: 1 Turbo Shaft
Airframe Total Time: 4420.5 Hours
Engine Manufacturer: LYCOMING
ELT:
Engine Model/Series: T53-L-703
Registered Owner: SAPPHIRE AVIATION LLC
Rated Power: 1300 hp
Operator: SAPPHIRE AVIATION LLC
Operating Certificate(s) Held: None 

N658H, was registered as a Bell UH-1H, helicopter with serial no. 67-17658. However, the current type certificate holder for that serial number is Rotorcraft Development Corporation.

The helicopter was manufactured in 1967 and according to a representative of the type certificate holder (Rotorcraft Development Corporation), was added to the type certificate on August 13, 2007. The helicopter was a single-engine helicopter powered by a Honeywell (formerly Lycoming) T53-L-703 turbo shaft engine with serial number LE-10462Z, which drove a two-bladed main rotor system and a two-bladed tail rotor. T53 engines are a two-spool engine. The gas generator spool consists of a five-stage axial compressor followed by a single-stage centrifugal compressor, and a two-stage high pressure turbine. The power turbine spool consists of two stages. The engine has a maximum continuous rating of 1,300 shaft horsepower at an output shaft speed of 6,634 rpm.

According to information received from the FAA, the accident helicopter was released from the General Services Administration in May 1996 and was owned and operated by seven other civilian operators before Sapphire Aviation, LLC, purchased it on February 10, 2017.

FAA records showed the helicopter was certificated as a restricted category aircraft for external load operations. Title 14 CFR 91.313 states in part that no person may be carried on a restricted category civil aircraft unless that person is a flight crewmember, is a flight crewmember trainee, performs an essential function in connection with a special purpose operation for which the aircraft is certificated, or is necessary to accomplish the work activity directly associated with that special purpose.

According to an inspection data sheet, updated on January 9, 2018, the helicopter had accumulated 4,420.5 hours of total time. 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Night
Observation Facility, Elevation: KRTN, 6349 ft msl
Distance from Accident Site: 11 Nautical Miles
Observation Time: 1753 MST
Direction from Accident Site: 282°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 10 knots /
Turbulence Type Forecast/Actual: / None
Wind Direction: 30°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 30.26 inches Hg
Temperature/Dew Point: 1°C / -18°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: RATON, NM (RTN)
Type of Flight Plan Filed: None
Destination: Folsom, NM
Type of Clearance: None
Departure Time: 1750 MST
Type of Airspace: 

At 1753, the recorded weather at RTN was: Wind 030° at 10 kts; visibility 10 statute miles; sky condition clear; temperature 1° C; dew point -18° C; altimeter 30.26 inches of mercury.

According to U.S. Naval Observatory Sun and Moon Data, the end of local civil twilight was 1735 and local moonset was at 1754. The observatory characterized the phase of the moon as "waxing crescent with 0% of the moon's visible disk illuminated."

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 4 Fatal, 1 Serious
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: On-Ground
Total Injuries: 5 Fatal, 1 Serious
Latitude, Longitude: 36.704444, -104.286667 (est) 

The main wreckage (fuselage) came to rest on a heading about 15° magnetic on a flat mesa about 10.7 nautical miles and 102° from RTN at an elevation about 6,932 ft mean sea level (msl). The mesa consisted mostly of small rocks and prairie grass. The area around the main wreckage was discolored and charred, consistent with a postaccident ground fire. There were no observed sources of ground light or illumination in the vicinity of the accident site.

The initial observed point of terrain contact was a parallel pair of ground scars, consistent with the width of the helicopter's skids, which led directly to the main wreckage on a 074° magnetic bearing. The distance from the start of the parallel ground scars to the wreckage was about 474 ft. About 18 ft past the end of the ground scars was a 25-ft-long ground scar consistent with a main rotor blade slap, which ran perpendicular to the path of travel. The entire main rotor came to rest about 60 ft beyond the blade slap signature. The tail rotor and tail rotor gear box were resting nearby. The helicopter's main wreckage was located about 66 ft beyond the main rotor. It came to rest upside down and the entire cabin section between the cockpit and tail boom was destroyed by fire.

The right side of the cockpit sustained thermal damage. The cyclic and collective on the left side of the cockpit were in place. The left cockpit side anti-torque pedals were present and connected to their under-deck push-pull tubes. The collective had broken away from its mount. Its twist grip linkage was present and connected. The twist grip's under-deck push-pull tubes moved when the grip's linkage was manipulated by hand. The push-pull tube sections located between the seats were been destroyed.

The collective control on the right side of the cockpit was separated from the floor deck. The right cyclic was not located. The right cockpit side's left anti-torque pedal was separated from it mount and the right anti-torque pedal was not located. Their connecting push-pull rod end were fractured into segments consistent with overload. All controls tubes aft of the cockpit were destroyed by fire.

Cockpit instruments and avionics exhibited discoloration, charring, and deformation consistent with thermal damage. Two altimeters were located. The altimeter on the left side of instrument panel read 6,760 ft (Kollsman window indicated 30.18). The other altimeter had separated from its instrument panel. The altimeter's 100-ft needle detached from its instrument face. However, the 1,000-ft needle pointed at 6,000 ft (Kollsman window indicated 30.28).

The transmission and main rotor mast were present forward of the engine and laying on its right side. The transmission's case had been consumed by fire, revealing the main drive gear and planetary gear train. The main drive gear was intact with no mechanical gear/tooth damage evident. The engine drive/sprag clutch was aligned with the transmission where a fragment of the KaFlex coupling was attached and was consistent in appearance with an overload fracture. Fragments of the KaFlex and torque tube were located in the debris field and displayed signatures consistent with overload fractures. The stationary swashplate was present with one servo connection present. The other two control servo connection horns were destroyed by thermal damage. Three flight control hydraulic servos were located. All aluminum hardware connecting each end of each servo had been melted or destroyed. The rotating swashplate was present with one scissor attached and the other scissor exhibited thermal damage. One main rotor blade damper remained attached to the rotor mast. The other blade damper was located in the debris field near the main rotor assembly. The mast had separated at the rotor head with a circumferential fracture consistent with torsional overload.

The engine compressor cases, accessory gearbox housing, and inlet housing were consumed by fire. The output reduction carrier and gear assembly, which attaches to the inlet housing, was intact and recovered as a loose component. Gears within the accessory gearbox were recovered as loose components. There were no penetrations of the combustor plenum. The exhaust tail pipe was disassembled from the engine while on scene to document the second-stage of the power turbine. There were metal spray deposits on the suction side of the second-stage power turbine stator vanes. There was no damage to leading edge of either the second-stage power turbine stator vanes or the second-stage power turbine rotor blades.

The left horizontal stabilizer had separated from the tail boom at its root. The right horizontal stabilizer remained attached to the tail boom.

Four of the 5 tail rotor drive shaft segments were aligned with the transmission and positioned along the top of the tail boom. The first drive shaft that spanned the space beneath the engine was not located; however, the steel end coupling was present at the aft end of the transit tube. All the drive shaft segments had detached from their coupling hanger bearings, except for the shaft connecting to the lower section of the intermediate (42°) gear box. The shaft extending upward from the 42° gear box had separated along with the tail rotor gear box. The 42° gear box remained attached to the tail boom. Oil was present in the case, and the gears could be rotated by hand. Tail rotor control push-pull tube was separated at the forward end of the tail boom. Control continuity was established from the forward section of the tail boom to the tail rotor gearbox mount. Control continuity from the forward section of the tail boom to the horizontal stabilizer was established. The tail rotor gear box, the attached drive shaft, tail rotor head, and both blades had been separated from the vertical tail and were located in debris field near the main rotor assembly. Oil was present in the tail rotor gear box. The tail rotor assembly remained intact. The pitch links were attached from the pitch horns to the cross head. Rotor head balance weights remained attached. The tail rotor shaft moved freely by hand, no binding in the gear box. The tail rotor red blade tip leading edge was peeled back, and the tip cap sheared off. The opposite blade had been bent outboard about 30° about midspan along the chord line.

The main rotor separated from the rotor mast at the bottom of the rotor head and showed a fracture surface consistent with torsional overload. Both main rotor blades (red and white) remained attached to their main rotor head blade grips. The stabilizer bar assembly had separated from the main rotor head and was located near the main rotor assembly. The pitch change links, the control tubes, and the mixing lever remained connected to the stabilizer bar assembly.

The majority of the red main rotor blade's fiberglass and honeycomb blade afterbody had separated from its blade spar. Portions of the afterbody panels were discolored black and brown consistent with exposure to fire. The length of the red blade was about 21 ft 8 in. The outboard tip portion of the red blade had separated. The outboard 5 ft of the blade exhibited a broomstraw appearance. The drag brace remained connected. The pitch horn had sheared off the blade grip at its mounting pad.

The majority of the white main rotor blade's fiberglass and honeycomb blade afterbody had buckled and separated from the spar at 4 locations. The white blade's tip had sheared from its blade at a 45° angle. The length of the white blade was about 20 ft. The outboard tip portion of the blade had separated. The outboard 1 ft of the blade exhibited a broomstraw appearance. The drag brace remained connected. The pitch horn had sheared off the blade grip at its mounting pad.

Medical And Pathological Information

The New Mexico Office of the Medical Investigator, Albuquerque, New Mexico, performed an autopsy of the pilot. The pilot's cause of death was blunt force trauma with atherosclerotic and hypertensive cardiovascular disease as contributing conditions. The autopsy revealed that the pilot's heart was enlarged, and both ventricles were thickened. Severe coronary artery disease was identified with up to 75% stenosis of the left anterior descending coronary artery and up to 40% stenosis of the left circumflex coronary artery. In addition, there was microscopic evidence of previous ischemia.

The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicology testing on specimens of the pilot. Etomidate was detected in heart blood, and 0.032 µg/mL of diphenhydramine was detected in femoral blood. Diphenhydramine was also detected in liver.

Review of postaccident treatment records indicated that the pilot was administered etomidate by paramedics following the accident.

Diphenhydramine is used for the treatment of the common cold and hay fever. It carries the following Federal Drug Administration warning: may impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery). The therapeutic range for diphenhydramine is 0.0250 to 0.1120 µg/ml. Diphenhydramine can cause marked sedation, altered mood, and impaired cognitive and psychomotor performance. In a driving simulator study, a single 50 mg dose of diphenhydramine impaired driving ability more than a blood alcohol concentration of 0.100 gm/dl.

Tests And Research

A cellphone and iPad were located in the wreckage and sent to the National Transportation Safety Board Vehicle Recorders Laboratory to be examined for data pertinent to the accident. The devices were found locked so no data was retrieved.

The NTSB conducted terrain mapping and viewpoint flights of the impact area using a small unmanned aircraft system. Video from the drone flights was overlaid with cockpit imagery from an exemplar helicopter as a visualization aid. The overlay showed that fewer visible terrain features were present near the accident area during night conditions than during day conditions. The UAS Aerial Imagery Factual Report is in the docket for this accident.

A review of local terrain revealed that, if the helicopter had flown directly from RTM to the destination, the terrain along the route would have been about 450 ft lower. The accident site was located about 4 nautical miles south of this route.

Additional Information

A witness at the ranch in the Folsom, New Mexico, area was asked if he knew the route of flight for previous helicopter flights to the ranch. He reported that the few times that the pilot would have flown to the ranch would have mainly been from Perry Stokes Airport, near Trinidad, Colorado. He was not familiar with how many trips the pilot would have made from RTN to the ranch, but indicated that "it was probably minimal."

FAA Advisory Circular (AC) 61-134, General Aviation Controlled Flight into Terrain Awareness, defines controlled flight into terrain (CFIT) as when an airworthy aircraft is flown, under the control of a qualified pilot, into terrain (water or obstacles) with inadequate awareness on the part of the pilot of the impending collision.

An Australian Transport Safety Bureau Aviation Research and Analysis Report stated that at night, the absence of peripheral visual cues, especially below the aircraft, can give an illusion of height, and result in the pilot inadvertently flying lower than necessary.

An article in The Journal of the Human Factors and Ergonomics Society, published in September 2008, titled Visual Misperception in Aviation: Glide Path Performance in a Black Hole Environment, stated that no pilot was immune from visual [spatial disorientation]. Pilots with more experience tended to fly even lower than those with less experience.



View looking towards the initial impact site.

Close-up view looking towards the initial impact site.

View looking towards RTN from the initial impact site.

View of the debris path looking towards the main wreckage.
View of a ground scar that is perpendicular to the debris path.
View from the ground scar looking towards the main wreckage.

View from the main rotor blades looking towards the main wreckage.


View from the separated left skid looking towards the main wreckage.

View from the separated right skid looking towards the main wreckage.

View of the main wreckage.

View of the engine in the main wreckage.

View of transmission gears.

View of liberated K-flex components.

View of engine turbine blades.

View of the engine during recovery.

Close-up view of an altimeter.

Close-up view of a coupling in the tail rotor drive system.

View of the left cockpit seat during recovery.

View of the intermediate tail rotor gearbox.

View of the tail rotor gearbox, a tail rotor blade, and tail rotor drive shaft.

Robinson R44 Raven I, N3264U: Accident occurred December 20, 2020 at Morris Municipal Airport (C09), Grundy County, Illinois

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. 

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

Additional Participating Entity: 
Federal Aviation Administration / Flight Standards District Office;  Des Plaines, Illinois 


Location: Morris, IL 
Accident Number: CEN21LA095
Date & Time: December 20, 2020, 16:45 Local 
Registration: N3264U
Aircraft: ROBINSON HELICOPTER R44
Injuries: 1 Minor
Flight Conducted Under: Part 91: General aviation - Personal

Aircraft and Owner/Operator Information

Aircraft Make: ROBINSON HELICOPTER
Registration: N3264U
Model/Series: R44 Aircraft 
Category: Helicopter
Amateur Built: No
Operator: 
Operating Certificate(s) Held: None
Operator Designator Code:

Meteorological Information and Flight Plan

Conditions at Accident Site: VMC
Condition of Light: Day
Observation Facility, Elevation: KC09,584 ft msl
Observation Time: 16:55 Local
Distance from Accident Site: 0 Nautical Miles
Temperature/Dew Point: 3°C /0°C
Lowest Cloud Condition: Clear
Wind Speed/Gusts, Direction: 6 knots / , 250°
Lowest Ceiling: 
Visibility: 10 miles
Altimeter Setting: 29.8 inches Hg
Type of Flight Plan Filed: None
Departure Point: Morris, IL 
Destination: Morris, IL

Wreckage and Impact Information

Crew Injuries: 1 Minor 
Aircraft Damage: Substantial
Passenger Injuries: N/A 
Aircraft Fire: None
Ground Injuries: N/A 
Aircraft Explosion: None
Total Injuries: 1 Minor
Latitude, Longitude: 41.42475,-88.418667 

A helicopter was blown onto its side by a gust of wind Sunday afternoon at Morris Municipal Airport in the far southwestern suburb, a spokesman for the Federal Aviation Administration confirmed.

At approximately 4:45 p.m., the pilot of a Robinson R44 helicopter was practicing a "touch and go" maneuver on the runway when the rotorcraft blew onto its side.

One person, the pilot, was aboard at the time, the Federal Aviation Administration said. Information about that individual's condition wasn't immediately available.

The incident remains under investigation by the Federal Aviation Administration and National Transportation Safety Board.

Piper PA-28-140, N1817J: Donated by Dr. Thomas W. Carey Jr. to Lincoln Land Community College aviation maintenance program




A Springfield man has donated his late father’s Piper Cherokee aircraft to the Lincoln Land Community College aviation program.

The plane donated by Dr. Thomas W. Carey Jr., a Lincoln Land alumnus, will be used by students for hands-on training experiences in aviation mechanics.

Lincoln Land is one of only three community colleges in the state that has an aviation mechanics training program.

The program has about 30 students and is housed at the Abraham Lincoln Capital Airport.

The 1968 Piper PA-28-140 fixed wing single-engine aircraft has four seats.

Thomas W. Carey Sr. purchased the aircraft in 1968. It was only the seventh one built of that particular model.

Carey Sr. was a pilot for more than 60 years and was a lieutenant colonel in the United States Army, serving in World War II, the Korean War and the Vietnam War.

“This model was very special,” Carey Jr. explained. “My father flew on missions in a similar aircraft during the Vietnam War and once returned back to base with numerous bullet holes in his plane.”

David Pietrzak, Lincoln Land's aviation program director, said he was grateful to the Carey family.

“It is an honor to continue use of this aircraft as a learning tool in our program to enhance our students’ hands-on training,” Pietrzak said.

One of the other planes used by Lincoln Land aviation students for training is a Learjet 24B that once belonged to actor John Travolta and singer/songwriter Paul Anka.

There is “a strong indication,” Pietrzak said, that it is the same chartered aircraft that billionaire and aerospace pioneer Howard Hughes died on in 1976. Hughes was on his way from Acapulco, Mexico, to Houston for emergency medical treatment when he died over south Texas.

Lincoln Land offers degrees in aviation mechanics and aviation management. Students also can earn airframe and powerplant certificates in 18 months.

Coronavirus prompts early closure of John Wayne-Orange County Airport (KSNA) tower; flights not affected



At least one air traffic controller at John Wayne-Orange County Airport appears to have contracted COVID-19, prompting the early closure of the facility’s tower on Sunday, December 20th, Federal Aviation Administration officials announced.

The tower will close seven hours early at 4 p.m., following reports of a “probable positive” case of coronavirus, Federal Aviation Administration officials said.

Air traffic will be monitored remotely by Southern California Terminal Radar Approach Control (TRACON) until regular operations resume Monday morning. The service normally takes over for local personnel after hours.  No flights will be impacted by the closure, according to the Federal Aviation Administration and Deanne Thompson, spokeswoman for John Wayne-Orange County Airport.

Thompson said no other part of the airport appears to have been contaminated. The rest of the facility remained fully operational Sunday.

“The tower is completely removed from the rest of the airport,” she said.  “It is unlikely that anyone working in the tower would have had any contact with airport staff.”

Tower staff had been instructed to self-quarantine last month when an air traffic controller tested positive for the coronavirus November 22nd. That resulted in reduced staffing just ahead of the Thanksgiving Holiday. However, no significant delays were expected at that time, either.

Destiny 2000, N65733: Incident occurred December 20, 2020 in Rio Linda, Sacramento County, California

Federal Aviation Administration / Flight Standards District Office; Sacramento, California

Aircraft lost power on takeoff and struck power lines. 


Date: 20-DEC-20
Time: 19:00:00Z
Regis#: N65733
Aircraft Make: EXPERIMENTAL
Aircraft Model: DESTINY POWERED PARACHUTE
Event Type: INCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: MINOR
Activity: PERSONAL
Flight Phase: TAKEOFF (TOF)
Operation: 91
City: RIO LINDA
State: CALIFORNIA
 

RIO LINDA, California — A man dressed as Santa Claus while on a powered parachute was rescued after getting stuck on some power lines in Sacramento County on Sunday morning.

The rescue was near 7th Avenue in Rio Linda, according to the Sacramento Metropolitan Fire District.

The California Highway Patrol’s North Sacramento Office also responded to the rescue, saying in a Facebook post that “Turns out Santa was trying to get some last-minute fun in before the holiday and got into a hot wire situation.”

The Federal Aviation Administration said the incident happened around 11 a.m. and the Santa had taken off near a school in Rio Linda.

"A powered parachute lost power on takeoff near a school in Rio Linda, California, and then hit and became suspended in power lines around 11:00 a.m. local time today," said a spokesperson with the Federal Aviation Administration.

Power was shut off to about 200 customers in the Rio Linda area during the rescue, according to officials with Sac Metro Fire.

“Immediately after power was shut off, we were able to move firefighters up into the power line and then lower the pilot -- Santa Claus -- down to safety,” said Chris Vestal with Sac Metro Fire.

According to Vestal, the man was trying to do something nice for kids in the community.

“He was trying to deliver candy canes to kids that were playing through in the community. We commend him for that. It’s unfortunate, but we all need to remember that there’s still good out in the world there are people doing good things and look at the brightness of the holiday season," Vestal said.

Thankfully, the Santa wasn’t hurt in the incident.




SACRAMENTO, California — A Santa pilot was rescued in Rio Linda on Sunday. Sacramento Metro Fire responded to an incident of a powered parachute getting stuck in some power lines on a power pole near 7th Ave. What they didn't expect to see was Santa Claus and his sleigh getting stuck in some power lines. Santa was flying a "hyper light" aircraft, according to Sacramento Metro Fire.

CHP North Sacramento also responded to the incident and posted about it on Facebook saying, "We typically don’t respond to a 'Rudolph lane-changed me' call, but when you get multiple calls... it’s best to go check it out."

SMUD was called to turn off the power before before Metro Fire helped get Santa down. About 200 homes were without power for a little bit.

"Turns out Santa was trying to get some last minute fun in before the holiday and got into a hot wire situation," CHP North Sacramento said in their Facebook post.

"We are happy to report Santa is uninjured and will be ready for Christmas next week, but perhaps with a new sleigh!" Metro Fire said in a tweet.

So no need to worry about Christmas presents not getting there on time because officials say Santa was not hurt in this incident. Santa was flying solo in his sleigh today, meaning Rudolph and all of the other reindeer are also safe, although the elves might have some work to do on the sleigh before Santa flies it out on Christmas Eve.

Senate Panel Rebukes Federal Aviation Administration in Wake of Boeing 737 MAX Tragedies

Commerce committee details agency lapses policing airlines and pilots, retaliation against those raising safety concerns


The Wall Street Journal
By Andy Pasztor
Updated December 20, 2020 12:45 pm ET

A congressional panel issued a report documenting what it determined were safety-oversight lapses by the Federal Aviation Administration, from agency intimidation of federally protected whistleblowers to lax policing of maintenance errors.

The 101-page document, released Friday by the Senate Commerce committee, is sharply critical of Federal Aviation Administration leadership’s handling of numerous matters over several years. The findings stem from the broadest review of agency enforcement efforts conducted in the wake of two fatal crashes of Boeing Co.’s 737 MAX jets.

Concluding that systemic Federal Aviation Administration deficiencies pose an “unnecessary risk to the flying public,” the report cited a pattern of agency managers avoiding responsibility for failures to ensure proper staff training. Managers also undermined or overruled enforcement decisions of some inspectors, investigators determined.

“When inspectors pushed back,” according to the report, “they were investigated and in some cases reassigned.”

After examining some 13,000 pages of documents and interviewing dozens of agency employees, investigators described a “failed Federal Aviation Administration safety management culture” tending to favor companies over Federal Aviation Administration staff and “often accompanied by retaliation against those who report safety violations.”

Specifics raised in the report pertain to two major United States passenger carriers, a number of big cargo airlines and smaller commercial-aircraft and helicopter operators.

The Federal Aviation Administration said it was reviewing the information, but sounded a skeptical note. The committee, according to the Federal Aviation Administration, acknowledges its report contains a number of unsubstantiated allegations.

A string of earlier reports by House lawmakers, accident investigators and independent safety experts focused on the MAX’s flawed flight-control system, which led to 346 fatalities and a nearly two-year global grounding of the fleet.

The strongest and newest details in the latest safety review, however, related to other aspects of the Federal Aviation Administration dealings with the industry. Investigators found what they described as agency abuses of voluntary disclosure practices the Federal Aviation Administration routinely relies on to learn of hazards discovered by carriers, pilots and mechanics.

Federal Aviation Administration inspectors “were pressured or coerced by Federal Aviation Administration managers” to accept such voluntary disclosures even though they clearly fell outside the bounds of program procedures and requirements, according to the report.

The report lays out instances of Southwest Airlines exerting “improper influence on the Federal Aviation Administration to gain favorable treatment.”

Early this year, a Federal Aviation Administration inspector reported that after pilots on a Southwest flight experienced persistent flight-control problems during takeoff, cruise and descent, the crew opted to fly another leg with the malfunctioning plane instead of alerting maintenance personnel. The second flight was beset by the same handling difficulties.

“Despite the intentional nature of the event” which should have precluded protections under voluntary disclosures, according to the report, Southwest successfully argued the behavior of the crew fit the program’s guidelines and they shouldn’t be subject to punishment.

An improperly done previous repair turned out to be the root cause of the control issue, which could have resulted in a crash, according to the report. But the inspector who originally investigated the flights and the flawed repair, according to the report, told the committee he was convinced Southwest was gaming the system and provided misleading information to the Federal Aviation Administration.

The same inspector, who refused to accept another voluntary disclosure from Southwest, in that case told investigators maintenance tape had been mistakenly left on a sensor of a Southwest jet but the captain failed to investigate the discrepancy or note it in the logbook before conducting two flights. A subsequent crew, according to the report, did note it in the logbook as required.

Federal Aviation Administration whistleblowers told investigators the tape was placed there for calibration purposes and “the result could have been catastrophic.” The report indicates Southwest refused to permit pilots to be interviewed unless their information was accepted unconditionally as a voluntary disclosure and any type of punishment was precluded.

Southwest said it was aware of the report and has used earlier discussion of some issues to improve internal practices, adding the carrier “maintains a culture of compliance” and recognizes “the safety of our operation as the most important thing we do.” A spokeswoman added “we absolutely disagree with allegations of improper influence,” because Southwest didn’t “inhibit or interfere with the Federal Aviation Administration ability to exercise oversight and investigative responsibilities.”

In another section, the Senate report indicated Boeing officials tried to skew Federal Aviation Administration ground-simulator tests in their favor in July 2019, months after the second 737 MAX accident. These officials, according to investigators, “inappropriately coached” Federal Aviation Administration pilots on how to respond swiftly to simulated emergencies. According to the report, Federal Aviation Administration and Boeing officials “had established a predetermined outcome to reaffirm” Boeing’s initial design assumptions and “were attempting to cover up important information that may have contributed to the 737 MAX tragedies.”

Boeing’s activities failed to persuade the  Federal Aviation Administration to quickly return the MAX to service,  Federal Aviation Administration officials have told House and Senate investigators. Ground-simulator testing later the same day by a more-senior Federal Aviation Administration pilot eventually led the agency to demand major software and training fixes that ended up delaying resumption of flights for more than a year.

The Senate probe also highlighted long-standing assertions by a Federal Aviation Administration whistleblower that when the MAX initially got the green light to fly passengers, some of the agency officials who vetted pilot-training requirements didn’t have the required experience and training for the job. In the past, the Federal Aviation Administration repeatedly denied those accusations.

The Federal Aviation Administration statement said the agency “conducted a thorough and deliberate review of the 737 MAX” before lifting the grounding order last month. The Federal Aviation Administration added all safety issues have been fully addressed “through the design changes required and independently approved by the Federal Aviation Administration,” along with foreign regulators.

Boeing said lessons from the dual MAX crashes “have reshaped our company and further focused our attention on our core values of safety, quality and integrity.”

Following a 20-month probe, Senate investigators mentioned persistent difficulties getting access to government documents and interviewing Federal Aviation Administration employees. The report described some testimony as conflicting and misleading. “The level of cooperation by the Federal Aviation Administration” and its parent agency, the Department of Transportation “has been unacceptable and at times has bordered on obstructive,” according to the committee.

Loss of Visual Reference: Piper PA-28-161 Cherokee, N556PU; fatal accident occurred March 05, 2019 in Fellsmere, Indian River County, Florida

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


Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Orlando, Florida
Piper Aircraft Company; Vero Beach, Florida
Lycoming; Williamsport, Pennsylvania 

Investigation Docket - National Transportation Safety Board:  

FlightSafety International 


Location: Fellsmere, Florida 
Accident Number: ERA19FA116
Date & Time: March 5, 2019, 07:03 Local 
Registration: N556PU
Aircraft: Piper PA28
Aircraft Damage: Substantial
Defining Event: Loss of visual reference 
Injuries: 1 Fatal
Flight Conducted Under:

Analysis

The student pilot was scheduled to complete a solo cross-country flight the day before the accident, and her flight instructor had provided the required endorsements for that flight; however, the flight was subsequently cancelled due to weather and was rescheduled for the following morning. When the pilot arrived on the airport the morning of the accident, she was released for the flight by the operations duty officer (DO), who was responsible for confirming that students had the proper endorsements for solo flight, even though her endorsements for the previous day's flight would have been no longer valid. The DO was also responsible for ensuring that weather conditions along a student's planned route of flight met the student’s prescribed limitations, and found that although the departure airport was reporting visual flight rules (VFR) conditions, the destination airports were reporting instrument flight rules (IFR) conditions. He stated that airports in the area tended to be IFR in the early-morning hours due to fog, then quickly improve to VFR after sunrise. He signed the pilot's flight risk assessment so that she could conduct her preflight inspection, but stressed to her that she needed to check the weather again before takeoff, and if conditions were still IFR, then the flight needed to be cancelled.

Between the time the DO released the pilot for the flight and the time she subsequently departed just after sunrise, weather conditions at the departure airport deteriorated from VFR to low IFR, including a cloud ceiling around 400 to 500 ft above ground level. The airplane likely entered instrument meteorological conditions (IMC) immediately after takeoff. A review of radar data revealed that the pilot flew west-northwest of the airport and made a series of climbing and descending turns before the airplane impacted terrain around 6 minutes after takeoff about 7.3 miles northwest of the airport. Postaccident examination of the airplane and the engine revealed no discrepancies that would have precluded normal operation. The airplane's radar track after takeoff did not suggest an immediate loss of control upon entering IMC; however, the climbing and descending turns near the end of the data are consistent with the known effects of spatial disorientation.

On the morning of the accident, four other students departed on solo flights. Three of the pilots departed just before the accident pilot. Two of these pilots stated that they checked the weather before their flights and conditions were VFR; however, it was still dark out and they could not see the clouds. All three pilots entered the clouds immediately after takeoff but were able to climb to a safer altitude and divert to another airport.

Students were required to obtain a weather briefing and file a flight plan as part of the preflight planning process. It could not be determined what weather information, if any, the pilot obtained the morning of the accident, and she did not file a flight plan for the flight.

The pilot was behind in her flight training schedule and had expressed concerns about being removed from the flight program. It is possible that she felt self-imposed pressure to complete the flight to remain in the program. Additionally, she may have assumed that she was cleared to conduct the flight upon being released by the DO, though previous communications with her instructor indicated that she was aware of the endorsement requirements.

Although the pilot should have known that her decision to depart on the flight without a flight plan and without an instructor endorsement met neither Federal Aviation Administration nor the school's published requirements, the DO should have recognized that the endorsements contained in her logbooks were for the previous day and not released the pilot for the flight without consulting the instructor.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The student pilot's loss of control due to spatial disorientation following an encounter with instrument meteorological conditions shortly after takeoff. Contributing to the accident was the failure of both the pilot and the flight school to ensure that the pilot had received the proper endorsements for the flight and the pilot’s self-imposed pressure to complete the flight in order to remain in the flight program.

Findings

Personnel issues Motivation/respond to pressure - Student/instructed pilot
Personnel issues Spatial disorientation - Student/instructed pilot
Personnel issues Aircraft control - Student/instructed pilot
Environmental issues Clouds - Effect on operation
Personnel issues Qualification/certification - Student/instructed pilot
Personnel issues Qualification/certification - Flt operations/dispatcher
Environmental issues Clouds - Contributed to outcome

Factual Information

History of Flight

Initial climb Loss of visual reference (Defining event)
Maneuvering Loss of visual reference
Uncontrolled descent Collision with terr/obj (non-CFIT)

On March 5, 2019, at 0703 eastern standard time, a Piper PA-28-161, N556PU, was substantially damaged when it was involved in an accident near Fellsmere, Florida. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 solo instructional flight.

The student pilot had been training at the FlightSafety International Inc. (FSI) FlightSafety Academy (FSA) in Vero Beach, Florida; the accident flight was her second solo cross-country flight. The Vero Beach Regional Airport (VRB) control tower was not open at the time of departure, and there were no recorded radio transmissions documenting the pilot's departure.

The airplane was first observed on radar shortly after it departed runway 30L at 0657:23. At that time it was at a groundspeed of 106 knots, and an altitude of 525 ft mean sea level (msl). For about the next 1 minute 30 seconds, the airplane flew on a westerly heading and descended to 325 ft msl and reduced groundspeed to 83 knots.

The airplane then made a right turn toward the northwest before making a left turn back to the southwest. The airplane slowed to a groundspeed of 70 knots and the altitude varied between 425 ft and 300 ft msl before it made a right turn to the north about 0700:36. At that time, the airplane was at a groundspeed of 79 knots, a heading of 336°, and an altitude of 625 ft msl.

Over the next 2 minutes 30 seconds, the airplane made a series of climbing and descending turns with varying groundspeeds and headings, before it entered a steep right turn at 0703:05. At that time, the airplane was at groundspeed of 93 knots, a heading of 242°, and an altitude of 725 ft msl. Over the next 34 seconds, the airplane continued to turn right before the data ended at 0703:39. At that time, the airplane was at a groundspeed of 117 knots, a heading of 153°, and an altitude of 550 ft msl.

The airplane impacted terrain about 1/4-mile south of the last radar return in heavily wooded farmland about 7.3 miles northwest of VRB. 

Student pilot Information

Certificate: Student 
Age: 24, Female
Airplane Rating(s): None
Seat Occupied: Left
Other Aircraft Rating(s): None 
Restraint Used: 3-point
Instrument Rating(s): None 
Second Pilot Present:
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 1 Without waivers/limitations
Last FAA Medical Exam: April 8, 2018
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time: 96 hours (Total, all aircraft), 96 hours (Total, this make and model), 6 hours (Pilot In Command, all aircraft), 47 hours (Last 90 days, all aircraft), 15 hours (Last 30 days, all aircraft)

The pilot's planned route on the day of the accident was VRB to Palm Beach County Glades Airport (PHK), Pahokee, Florida, to Okeechobee County Airport (OBE), Okeechobee, Florida, to VRB. According to her logbook, she had completed this same route numerous times with a flight instructor and once as a solo cross-country flight.

A review of text messages provided by the instructor and the pilot's previous instructor revealed that the pilot's initial flight instructor at FSA would not endorse her for solo flight and recommended that she be removed from the flight program. FSA subsequently assigned her a new instructor, who stated that the pilot "was fine" and endorsed her for a solo cross-country flight. This instructor then left FSA, and the pilot was assigned to her current flight instructor.

The pilot's current flight instructor stated that she had only flown with the pilot twice before the accident, both of which were dual cross-country flights. The instructor described the pilot as a "remedial student" who had expressed concern that she would be released from the flight program due to her high flight time. The pilot knew that she needed to complete the solo cross-country flights to remain in the training program.

A review of the pilot's training records, and lesson plans revealed that she started her private pilot training in March 2018 and logged her first training flight on June 11, 2018. She was scheduled to have completed the private pilot course by March 1, 2019. A review of her lesson plans revealed that she had 34 unsatisfactory lessons and 36 satisfactory lessons.

Aircraft and Owner/Operator Information

Aircraft Make: Piper 
Registration: N556PU
Model/Series: PA28 161
Aircraft Category: Airplane
Year of Manufacture: 2000 
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 2842093
Landing Gear Type: Tricycle 
Seats: 4
Date/Type of Last Inspection: March 3, 2019 AAIP
Certified Max Gross Wt.: 2447 lbs
Time Since Last Inspection: 4 Hrs
Engines: 1 Reciprocating
Airframe Total Time: 13103.4 Hrs at time of accident
Engine Manufacturer: Lycoming
ELT: C126 installed, activated, did not aid in locating accident
Engine Model/Series: O-320-D3G
Registered Owner: 
Rated Power: 160 Horsepower
Operator: 
Operating Certificate(s) Held: Pilot school (141)

Meteorological Information and Flight Plan

Conditions at Accident Site: Instrument (IMC) 
Condition of Light: Day
Observation Facility, Elevation: VRB,23 ft msl
Distance from Accident Site: 7 Nautical Miles
Observation Time: 07:03 Local
Direction from Accident Site: 120°
Lowest Cloud Condition: Unknown
Visibility: 6 miles
Lowest Ceiling: Overcast / 400 ft AGL Visibility (RVR):
Wind Speed/Gusts: 8 knots / 
Turbulence Type Forecast/Actual: None / None
Wind Direction: 250°
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 30 inches Hg 
Temperature/Dew Point: 19°C / 18°C
Precipitation and Obscuration: N/A - None - Mist
Departure Point: Vero Beach, FL (VRB)
Type of Flight Plan Filed: None
Destination: Pahokee, FL (PHK)
Type of Clearance: None
Departure Time: 06:57 Local 
Type of Airspace: Class D; Class E

From the time the student pilot arrived at VRB to the time she departed and the airplane impacted terrain, the weather had deteriorated from visual flight rules to instrument flight rules conditions. Sunrise was at 0642.

The 0553 weather reported at VRB included wind from 230° at 4 knots, 10 miles visibility, light rain, scattered clouds at 2,700 ft above ground level (agl), broken clouds at 10,000 ft agl, temperature 18°C, dewpoint 17° C, with an altimeter setting of 30.00 inches of mercury (inHg).

At 0653, the wind was 270° at 7 knots, 8 miles visibility, light rain, ceiling broken at 500 ft agl, overcast clouds at 1,900 ft agl, temperature 19°C, dewpoint 18°C, and an altimeter setting of 30.03 inHg.

At 0703, the wind was 250° at 8 knots, visibility 6 miles, light rain and mist, ceiling overcast at 400 ft agl, temperature 19° C, dewpoint 18° C, and an altimeter setting of 30.03 in Hg.

Similar conditions were reported 13 miles south of the accident site at Treasure Coast International Airport (FPR), Fort Pierce, Florida, which reported at 0715 wind from 270° at 7 knots, 2 1/2 miles visibility in mist, ceiling overcast at 300 ft agl, temperature 19°C, dew point 18°C, altimeter 30.04 inHg.

A review of the terminal aerodrome forecast (TAF) for VRB on the morning of the accident revealed it was issued at 0044 and was amended at 0632, about 25 minutes before the pilot's departure. The 0044 forecast expected variable winds of 3 knots, visibility unrestricted at 6 miles or more, with broken clouds at 1,500 ft agl between 0300 and 0900. The 0632 forecast reported no change in the forecast through 0900.

The TAF was amended after the accident at 0741 and expected a temporary period of instrument flight rules (IFR) conditions between 0700 and 0900 with visibility of 2 miles in mist with a ceiling overcast at 300 ft.

The National Weather Service issued AIRMET Sierra at 0345, which was current until 1000, for IFR conditions over Florida and the coastal waters, which included the accident site, for ceiling below 1,000 ft agl and visibilities below 3 miles in mist.

FSA required students to obtain their own weather briefings as part of the preflight planning process. The school had a separate room where students could call Leidos Flight Service (LFS) to obtain weather briefings and file flight plans. There were also computers available to obtain weather information and file flight plans electronically. According to the flight school, the computers used to obtain weather information do not require a student to sign in, so there was no record available to determine if the pilot used one of the school's computers to obtain weather information before the accident flight.

According to LFS, neither they nor any of the other vendors that use the LFS database, provided the student pilot any services (weather briefing, flight plan filing) before the accident flight.

A review of FSA's Aviation Safety Action Program (ASAP) dispatch occurrence forms submitted by the four other FSA pilots who flew on the morning of the accident revealed that two of the pilots specifically stated that they had checked the METAR and TAF before they departed and weather was VFR. However, it was still dark out and they could not see the cloud bases. Both pilots departed between 0630 and 0650 and entered the clouds on takeoff between 400 and 700 ft agl. Both pilots were able to climb above the clouds and divert to another airport. Another pilot, who did not specifically say that he checked weather that morning, said that the sky was "dim and gray" and he departed at 0645. After takeoff, he entered the clouds at 600 ft agl, but was able to climb and divert to another airport. The fourth pilot was the first on the flight line that morning and said that the ceiling and visibility were good, and he departed at 0610. The pilot flew east and noted that the cloud layers were not good for practicing maneuvers, so he returned to VRB. He said that the ceiling height was dropping quickly, but he was able to maintain visual contact with the airport and land.

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries:
Aircraft Fire: None
Ground Injuries: 
Aircraft Explosion: None
Total Injuries: 1 Fatal 
Latitude, Longitude: 27.715,-80.527221

The airplane’s initial impact point was an approximate 30-ft-tall tree; the wreckage path continued about 460 ft through trees and the airplane came to rest on its right side on a magnetic heading of about 115°. All major components of the airplane were located at the accident site and there was no post-impact fire.

The airplane's right wing, left wing, section of left stabilator, baggage door, nose gear fork, left main gear, engine cowling, pilot's seat, and a section of the outboard seat rail were found along the wreckage path. The main wreckage included the propeller, engine, fuselage, empennage, vertical stabilizer, rudder, and right stabilator.

The left wing separated from the airframe at the wing root and exhibited extensive leading-edge impact damage. The fuel tank was breached. The aileron and flap remained partially attached to the wing. The aileron cables remained attached at the bell crank and exhibited broomstraw fractures.

The right wing separated at the wing root and was fractured into two sections. The outboard section of wing sustained extensive impact damage. The inboard section (fuel tank) was breached. The flap and aileron remained attached to their respective hinges. The aileron cables were attached to the bell crank and the ends exhibited broomstraw fractures.

The wing flap handle was in the 10° flaps-extended position; the flap torque tube was dislodged from its supporting structure.

Measurement of the stabilator trim jackscrew corresponded to a slight nose-down position.

The vertical stabilizer sustained some impact damage. The rudder remained partially attached. The stabilator remained attached to the fuselage. The right side of the stabilator exhibited leading edge damage and the stabilator was deformed aft. The leading edge of the left side of the stabilator was separated from the assembly and displayed impact damage.

Flight control continuity was established from all flight control surfaces to the cockpit. Any breaks in the system exhibited broomstraw fracturing consistent with overstress.

The cockpit area sustained impact damage. The throttle was in the idle position and the mixture was in the full lean position. The carburetor heat was off. The navigation lights and pitot heat were off. The pilot's seat was separated from the fuselage and its seat frame was fractured and deformed to the left. The pilot's outboard seat track and supporting structure were separated from the fuselage. The airplane was equipped with shoulder harnesses for each of the four seat positions. The pilot's restraint system remained attached to its fuselage attaching points. Its inboard latch assembly webbing was separated about 6 inches from its attaching point and the latch was not located within the recovered wreckage. Field testing of its shoulder harness inertia reel determined it to be functional.

The attitude indicator and directional gyro were removed and disassembled. The gimbals for each were intact, and no scoring was noted on the interior of either drum casing.

The fuel selector was found in the right main tank position. The valve moved freely to each detent when manually turned. The fuel lines to the valve were fractured. The fuel strainer remained attached to the firewall, but the cap was partially dislodged from the bowl. No fuel was found in the bowl, and the screen was not located. The electric boost pump was intact. The cap and screen were removed. A small amount of fuel was found in the pump and the screen was absent of debris. The fuel finger screen was intact on the left wing and absent of debris. The right-wing screen was separated from impact and not located. The carburetor was removed and disassembled. The metal floats were intact, and some fuel was found in the bowl. The fuel screen was absent of debris. The engine-driven fuel pump was removed. The pump moved freely when manually operated and produced suction and compression.

No mechanical discrepancies were noted that would have precluded normal operation of the airplane.

The two-bladed propeller remained attached to the engine. The spinner was crushed inward. Both blades exhibited "S" bending with leading edge polishing, leading edge deformation, and chordwise scratching out to the tip of the propeller.

The engine remained attached to the airframe and exhibited some impact damage. The upper engine cowling was impact damaged and separated from the fuselage. The lower engine cowlings were fragmented, and thermal damage was observed to a small area near the gascolator assembly.

Compression and valve train continuity were established on each cylinder by manual rotation of the propeller.

The vacuum pump was removed. The pump rotated freely when manually rotated. The pump was disassembled, and the coupling, drum, and vanes were undamaged.

The magnetos were removed, and the ignitions leads were cut near the terminals. Both magnetos were manually rotated and produced spark at each terminal.

The top and bottom spark plugs were removed. The Nos. 2 and 4 plugs were oil-soaked, and the Nos. 1 and 3 plugs were gray, consistent with normal wear per the Champion Check-A-Plug chart.

The oil sump was intact and filled with oil. The screen was absent of debris. The oil filter sustained impact and could not be opened.

No discrepancies were noted that would have precluded normal operation of the engine.

The airplane's 406-MHz emergency locator transmitter (ELT) remained in the empennage but had come loose from its mount and was still connected via coaxial cables. The unit was armed, beeping, and a small red light was flashing on the unit. The ELT antenna had separated from the airframe during impact. A metallurgical examination of the fractured section that attached the antenna to the airframe revealed it was fractured on a slant plane relative to its longitudinal axis, consistent with overstress separation from impact. As a result, there was no way for the ELT to transmit the emergency signal, which delayed finding the airplane for several hours.

Additional Information

Under 14 CFR 61.93(c)(3), a flight instructor is required to endorse a student pilot's logbook for each solo cross-country flight. A review of the endorsements section of the pilot's personal logbook and a secondary logbook kept by FSA revealed she had not been endorsed for the accident flight by her flight instructor. According to the instructor, she and the student met the day before to review weather conditions, the navigation log, and her planning for a flight that day, and the instructor endorsed the student for the flight; however, that flight was subsequently cancelled due to weather. The instructor then requested that the student reserve an airplane in the afternoon the following day to complete the flight. FSA's scheduling department was unable to book the flight for the afternoon and it was scheduled for 0600 instead.

The instructor knew that there was a high probability that the flight would not take place the morning of the accident due to weather, and she did not establish a time to meet with the student on the morning of the accident flight. The instructor expected to hear from the student the following morning to repeat the flight planning review/endorsement process if the weather was adequate for the flight, but when she did not hear from the student or the flight school, she assumed that the flight was again cancelled due to weather. The instructor was not aware that the student had departed until the operations duty officer (DO) called her later that morning attempting to locate the pilot. She then also attempted to contact the pilot but received no response. She subsequently contacted LFS and learned that the student had not filed a flight plan, which she was required to do per FSA policy.

FSA required all students who did not hold a private pilot certificate to have a signed "lesson sheet" and weather endorsement by their flight instructor before they met with the school's DO on solo flights. The DO was then responsible for reviewing the student pilot's knowledge of the current and forecasted weather conditions, planned/alternate routes, applicable regulations, safe operating practices, and noise abatement procedures by using scenario-based questions. The DO was also responsible for verifying that the student pilot's flight risk assessment tool was completed, and the appropriate risk identification and mitigation measures were being taken in accordance with FSA procedures. The DO would confirm the student pilot's route of flight and verify that weather conditions did not exceed the limitations set by the student's flight instructor. Additionally, the DO was required to verify that the student had the proper solo flight endorsements in both their personal and FSA logbooks.

The DO on duty the morning of the accident stated that students began arriving about 0545. Of the five students scheduled to fly that morning, only the accident pilot was scheduled for a solo cross-country flight.

The DO stated that he reviewed the accident pilot's lesson sheet and verified that both of her logbooks had the appropriate instructor endorsements. He said, "...I reviewed weather conditions using SkyVector and found that VRB was reporting VFR, while OBE and FPR were reporting IFR. Because of the tendency for airports in the area to be IFR in the early-morning hours due to fog, then quickly go VFR after sunrise, I signed [student pilot]'s FRAT so she could conduct her preflight inspection, but stressed she must check the weather again before take-off and must cancel the flight if the weather along her intended route was still IFR." He then signed and dated the lesson sheet and released the pilot for the flight.

Per the FSA Training Regulations manual:

Solo cross-country flights may not depart unless VFR weather of not less than 2000' ceiling and 5 miles visibility is reported and forecast along the intended route. This restriction applies to predominant forecasted weather …. It is permissible to depart VRB with reported/forecast weather below stated minimums at the destination, provided the forecast at the estimated time of arrival is at or above required minimums.

An FSA lesson sheet was found in the wreckage on the pilot's kneeboard. The sheet was signed by her flight instructor but was not dated. It was also signed and dated for the day of the accident by the DO. The instructor stated that she signed the lesson sheet the day before the accident for the flight that was cancelled, and that the lesson sheet would have been invalid for any future flights without the accompanying, current-dated logbook endorsements for the flight on March 5, 2019.

Medical and Pathological Information

The District 19 Medical Examiner's Office for Indian River County, Florida, performed the autopsy on the pilot. The cause of death was determined to be "multiple blunt trauma injuries." 

Toxicological testing performed at the FAA Forensic Sciences Laboratory was negative for all substances tested.