Thursday, January 28, 2021

System/Component Malfunction/Failure (Non-Power): Piper PA-38-112 Tomahawk, N2452C; fatal accident occurred February 22, 2017 in East Haven, New Haven County, Connecticut

 NNH-CV19-6089055-S 


MATTA-ISONA, MARIE, ADMINISTRATRIX OF THE ESTATE O v. AMERICAN FLIGHT ACADEMY, LLC Et Al 


NEW HAVEN, Connecticut (AP) — The sister of a student pilot who died in a small plane crash in Connecticut in 2017 has settled a wrongful-death lawsuit against the flight school she accused of failing to maintain the aircraft.

Terms of the settlement over the death of Pablo Campos-Isona during a training flight crash in East Haven have not been disclosed. The agreement with the now-defunct American Flight Academy was revealed in a document filed Monday in New Haven Superior Court by the attorney for Campos-Isona’s sister, Marie Matta-Isona.

Messages seeking comment were left for lawyers in the case Wednesday.

Campos-Isona, 31, died after a Piper PA38 crashed while he and instructor Rafayel Hany Wassef were practicing touch-and-go landings near Tweed New Haven Airport on February 22, 2017. Wassef survived but suffered multiple broken bones.

American Flight Academy and its owner, Arian Prevalla, denied the lawsuit’s allegations and, in court documents, blamed Campos-Isona for the crash.

Federal investigators concluded a fuel selector valve failure likely caused the plane’s engine to stall and placed some blame on Wassef.

American Flight Academy also was sued over a 2016 fatal training flight crash in East Hartford, but a judge dismissed the lawsuit in 2019. In that case, Prevalla, who survived the crash, accused student Feras Freitekh, who died, of intentionally causing the crash, which Freitekh’s family denied.
 
 31-year-old student pilot Pablo Campos Iona and flight instructor, 20-year-old Rafayel Hany Wassef.











Aviation Accident Final Report - National Transportation Safety Board

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

Additional Participating Entities: 
Federal Aviation Administration / Flight Standards District Office; Windsor Locks, Connecticut
Lycoming Engines; Williamsport, Pennsylvania
Piper Aircraft; Vero Beach, Florida 

Investigation Docket - National Transportation Safety Board:

International Aviation LLC

Location: East Haven, CT
Accident Number: ERA17FA112
Date & Time: 02/22/2017, 0956 EST
Registration: N2452C
Aircraft: PIPER PA38
Aircraft Damage: Destroyed
Defining Event: Sys/Comp malf/fail (non-power)
Injuries: 1 Fatal, 1 Serious
Flight Conducted Under: Part 91: General Aviation - Instructional

Analysis 

The flight instructor and the student pilot were practicing touch-and-go landings in the airplane. During the initial climb after the fourth landing, the flight instructor reported an emergency to air traffic control and indicated that he was going to return and land on a runway at the airport. During that transmission, a stall warning horn was sounding. The airplane then spun to the left and descended to impact in a marsh.

The damage to the airplane was consistent with the airplane being in a left spin at impact, and the propeller displayed little damage, which is consistent with the engine not producing power at impact. The fuel selector handle was found positioned to the right main fuel tank; however, examination of the fuel selector's polymeric insert revealed that it had fractured and was in a position that provided openings of about 20% for the right main fuel tank inlet and for the engine outlet, instead of the 100% openings that would have been present with an intact polymeric insert. With only 20% of the normal fuel flow available, the airplane likely experienced a total loss of engine power due to fuel starvation. One of the pilots likely switched fuel tank positions during the previous touch-and-go landing, and the polymeric insert failed at that time. Examination of the wreckage did not reveal any other preimpact mechanical malfunctions.

Metallurgical examination of the fuel selector valve revealed that the lower portion of the polymeric insert exhibited fracture features consistent with rotational ductile overstress. Abrasive wear was present on the outer portion of the insert due to contact with burs on the valve housing. The wear likely took place over a period during which the fuel selector handle would have been difficult to move and excessive force would have been required to move the handle from one position to another.

Review of maintenance records did not reveal any prior anomalies with the fuel selector. The airplane maintenance manual contained instructions, applicable to 100-hour inspections, for the fuel selector to be inspected for condition, security, and operation. The instructions stated that, if the valve binds, sticks, or is otherwise difficult to operate, the fuel selector valve should be lubricated. However, about 5 months had passed since the most recent 100-hour inspection was completed on the airplane. During that time, the airplane had been operated about 78 hours. The investigation could not determine the condition of the fuel selector valve at the last 100-hour inspection.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The failure of the fuel selector valve in a position that restricted fuel flow to the engine, resulting in a total loss of engine power during initial climb due to fuel starvation. Also causal was the operator's failure to effectively detect and resolve the wear and progressive binding of the fuel selector valve before it failed due to excessive rotational force being applied. Contributing was the flight instructor's exceedance of the airplane's critical angle of attack during an emergency return to the airport, which resulted in an aerodynamic stall/spin. 

Findings

Aircraft
Fuel selector/shutoff valve - Failure (Cause)
Fuel selector/shutoff valve - Fatigue/wear/corrosion (Cause)
Fuel selector/shutoff valve - Not serviced/maintained (Cause)
Angle of attack - Capability exceeded (Factor)

Personnel issues
Aircraft control - Instructor/check pilot (Factor)

Factual Information

History of Flight

Initial climb
Sys/Comp malf/fail (non-power) (Defining event)
Fuel starvation
Loss of engine power (total)

Emergency descent
Aerodynamic stall/spin

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

Location: East Haven, CT
Accident Number: ERA17FA112
Date & Time: 02/22/2017, 0956 EST
Registration: N2452C
Aircraft: PIPER PA38
Aircraft Damage: Destroyed
Defining Event: Sys/Comp malf/fail (non-power)
Injuries: 1 Fatal, 1 Serious
Flight Conducted Under: Part 91: General Aviation - Instructional 

On February 22, 2017, about 0956 eastern standard time, a Piper PA-38-112, N2452C, was destroyed when it impacted terrain in East Haven, Connecticut, during the initial climb from Tweed-New Haven Airport (HVN), New Haven, Connecticut. The flight instructor was seriously injured, and the student pilot was fatally injured. The airplane was operated by American Flight Academy as an instructional flight conducted under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan was filed for the local flight.

According to an air traffic control transcript provided by the Federal Aviation Administration (FAA), the airplane completed four touch-and-go landings on runway 20, a 5,600-ft-long by 150-ft-wide asphalt runway. At 0955:43, during initial climb after the fourth landing, one of the pilots declared an emergency and stated, "mayday mayday mayday we're going to land on the other runway." The controller cleared the airplane to land, and no further communications were received from the pilots. Another flight instructor, who was also flying in the HVN airport traffic pattern at the time of the accident, stated that he heard the emergency transmission and could hear the airplane's stall warning horn in the background during the transmission. According to a witness, the airplane then spun to the left, descended in a nose-down attitude, and impacted terrain about 1,000 ft southeast of the departure end of runway 20. Review of radar data did not reveal any targets that could be correlated with the accident airplane during the initial climb in which the accident occurred.

The flight instructor was subsequently interviewed at a hospital by an FAA inspector. The flight instructor told the FAA inspector that he remembered practicing airwork and then returning to the airport to practice touch-and-go landings, but he did not recall the accident sequence. 

Flight Instructor Information

Certificate: Flight Instructor; Commercial
Age: 20, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): Airplane Single-engine
Toxicology Performed: Yes
Medical Certification: Class 1 With Waivers/Limitations
Last FAA Medical Exam: 11/14/2014
Occupational Pilot: Yes
Last Flight Review or Equivalent: 12/23/2016
Flight Time:  236.3 hours (Total, all aircraft), 11.9 hours (Total, this make and model), 30.9 hours (Last 90 days, all aircraft), 27.8 hours (Last 30 days, all aircraft) 

Student Pilot Information

Certificate: None
Age: 31, Male
Airplane Rating(s): None
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): None
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: None
Last FAA Medical Exam:
Occupational Pilot:  No
Last Flight Review or Equivalent:
Flight Time: 16.8 hours (Total, all aircraft), 14.6 hours (Total, this make and model), 3 hours (Last 90 days, all aircraft), 2.1 hours (Last 30 days, all aircraft) 

The flight instructor held a commercial pilot certificate with ratings for airplane single-engine land, airplane multi-engine land, and instrument airplane. He also held a flight instructor certificate with a rating for airplane single-engine. His most recent FAA first-class medical certificate was issued on November 14, 2014. Review of the flight instructor's logbook revealed that he had accumulated a total flight experience of about 236 hours, of which 12 hours were in the same make and model as the accident airplane. The flight instructor had flown about 28 hours during the 30-day period preceding the accident.

Review of the student pilot's logbook revealed that he had accumulated a total flight experience of about 17 hours of which 15 hours were in the same make and model as the accident airplane. The student pilot had not yet flown solo. 


Aircraft and Owner/Operator Information

Aircraft Manufacturer: PIPER
Registration: N2452C
Model/Series: PA38 112
Aircraft Category: Airplane
Year of Manufacture:
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 38-79A0192
Landing Gear Type: Tricycle
Seats: 2
Date/Type of Last Inspection: 09/30/2016, 100 Hour
Certified Max Gross Wt.: 1670 lbs
Time Since Last Inspection: 78 Hours
Engines: 1 Reciprocating
Airframe Total Time: 8472.9 Hours at time of accident
Engine Manufacturer: Lycoming
ELT: C91A installed, activated, did not aid in locating accident
Engine Model/Series: O-235
Registered Owner: INTERNATIONAL AVIATION LLC
Rated Power: 112 hp
Operator: INTERNATIONAL AVIATION LLC
Operating Certificate(s) Held: None
Operator Does Business As: American Flight Academy
Operator Designator Code: 

The two-seat, low-wing, fixed tricycle-gear airplane was manufactured in 1978. It was powered by a Lycoming O-235, 112-horsepower engine, equipped with a two-blade, fixed-pitch Sensenich propeller.

Review of the airplane's logbooks revealed that, at the time of the accident, the airframe had accumulated about 8,473 total hours of operation, and the engine had accumulated 2,508 hours since major overhaul. The airplane had been operated for 78 hours since its most recent 100-hour inspection, which was completed on September 30, 2016. Review of maintenance records did not reveal any prior anomalies with the airplane's fuel selector. Review of the airplane maintenance manual revealed instructions, applicable to 100-hour inspections, for the fuel selector to be inspected for condition, security, and operation. According to the instructions, if the fuel selector valve binds, sticks, or is otherwise difficult to operate, the fuel selector valve should be lubricated. Specifically, the insert, position washer, and "O" rings should be lubricated. 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: HVN, 12 ft msl
Observation Time: 0953 EST
Distance from Accident Site: 1 Nautical Miles
Direction from Accident Site: 360°
Lowest Cloud Condition:
Temperature/Dew Point: 6°C / 2°C
Lowest Ceiling: Overcast / 7500 ft agl
Visibility:  10 Miles
Wind Speed/Gusts, Direction: 5 knots, 210°
Visibility (RVR):
Altimeter Setting: 30.03 inches Hg
Visibility (RVV):
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: East Haven, CT (HVN)
Type of Flight Plan Filed: None
Destination: East Haven, CT (HVN)
Type of Clearance: None
Departure Time: 0955 EST
Type of Airspace:

The reported weather at HVN, at 0953, included wind from 210° at 5 knots, visibility 10 statute miles, and an overcast ceiling at 7,500 ft. 

Airport Information

Airport: Tweed-New Haven Airport (HVN)
Runway Surface Type: Asphalt
Airport Elevation: 12 ft
Runway Surface Condition: Dry
Runway Used: 20
IFR Approach: None
Runway Length/Width: 5600 ft / 150 ft
VFR Approach/Landing: None 

Wreckage and Impact Information

Crew Injuries: 1 Fatal, 1 Serious
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal, 1 Serious
Latitude, Longitude:   41.253611, -72.885556 

No debris path was observed, and the wreckage came to rest upright in a marsh, oriented on a near north magnetic heading. Both wings remained attached to the airframe, and the ailerons and flaps remained attached to their respective wings. The ailerons were about neutral, and the flaps were partially extended. The fuel caps remained secured to their respective wing fuel tanks, and, although both wing fuel tanks were breached during impact, several gallons of fuel remained in each wing. The right wing was buckled. The left wing exhibited more leading edge damage than the right wing, and its wingtip was bent upward, consistent with the left wing impacting terrain before the right wing.

The empennage was curled up and to the left. The horizontal stabilizer, vertical stabilizer, rudder, and elevator remained intact. Flight control continuity was confirmed from all flight control surfaces to the cockpit area. Examination of the elevator trim wheel revealed that the elevator trim cable remained wrapped around the spool twice, which equated to an elevator trim position between neutral and full nose up. Examination of the cockpit revealed that the seatbelts and shoulder harnesses remained intact. The throttle and mixture levers were in the forward position, and the magnetos were selected to both. The fuel selector handle was found positioned to the right main fuel tank.

The engine was partially buried in mud but remained attached to the airframe, and the propeller remained attached to the engine. The two propeller blades did not exhibit rotational damage. The wreckage was further examined at a recovery facility, and the engine was separated from the airframe for the examination. The valve covers were removed, and oil was noted throughout the engine. The top spark plugs were removed, and the propeller was rotated by hand. Camshaft, crankshaft, and valve train continuity were confirmed to the rear accessory section. Thumb compression was attained on all cylinders. The engine-driven fuel pump was removed from the engine. Several drops of fuel were recovered from the pump. When the pump was actuated by hand, suction and compression were confirmed at the inlet and outlet ports. The electric fuel pump activated when connected to a battery.

The throttle and mixture cables remained attached to the carburetor. The carburetor was disassembled, and its float and needle were intact. The carburetor inlet screen was absent of contamination. The carburetor bowl contained a mixture of fuel and water, consistent with its submersion in the marsh. The oil filter was opened, and no contamination was observed. The left magneto remained attached to the engine and produced spark at all four leads when rotated by hand. The right magneto had separated from the engine during impact and did not produce spark when rotated. The right magneto was disassembled, and the plastic housing that secured the breaker points was found fractured, resulting in no gap in the points. The spark plug electrodes remained intact and exhibited normal wear signatures when compared to a Champion Aviation Check-A-Plug chart. The bottom spark plugs exhibited corrosion consistent with submersion in the brackish marsh water.

During the airframe examination, the fuel selector valve would not move when the fuel selector handle was moved. The fuel selector was then removed and partially disassembled for examination. The examination revealed that the fuel selector valve's polymeric insert had fractured and was in a position that provided openings of about 20% to the right main fuel tank inlet and to the engine outlet, instead of the 100% openings that would have been present with an intact polymeric insert. The fuel selector valve was retained and forwarded to the NTSB Materials Laboratory, Washington, DC.

Metallurgical examination of the fuel selector valve revealed that the lower portion of the polymeric insert exhibited fracture features consistent with rotational ductile overstress. Abrasive wear was present on the outer portion of the insert due to contact with burs on the valve housing. (For more information, see the Materials Laboratory Factual Report in the public docket for this accident.) 

Medical And Pathological Information

The State of Connecticut, Office of the Chief Medical Examiner performed an autopsy on the student pilot. The cause of death was reported as blunt trauma.

Toxicological testing was performed by the FAA Bioaeronautical Science Research Laboratory, Oklahoma City, Oklahoma, on samples from both pilots. The results were negative for the student pilot. Positive results for the flight instructor were consistent with the emergency medical treatment that he received after the accident.

Robert Gretz, National Transportation Safety Board senior air safety investigator. 



















Isona v. American Flight Ac... by Ellyn Santiago

13 comments:

  1. How is it possible to have a commercial multi engine IFR instructor ticket with only 236 hrs tt

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    Replies
    1. I thought the same thing when I looked at his hours. In the US you have to have 250 hours to even qualify for your commercial rating irrelevant of your instrument and multi rating. Assuming you had your instrument and multi by that 250 hour qualifier, add on another 100 hours or so for the full multi IFR instructor rating. Yeah, his hours don't measure up. Was he a foreign exchange instructor or something where a nation has lesser requirements than the US? In any event, why don't we have an answer from the FAA on why the instructor was not even legally FAR qualified to get a basic single engine commercial rating?

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  2. Amazing that the flight school blamed the student pilot for the accident in court documents. If they were still in business, they'd not be for long.

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    Replies
    1. Appears to be Standard Operating Procedure for this "flight school".

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  3. CFI Tip: Dont ever change tanks during takeoff/landings/touch and go. Switch tanks at Pattern altitude if needed, at an altitude where a power off landing is assured. Thats my practice and what I teach

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    Replies
    1. Yep. I don't fool with selector valves below 1,000' AGL.

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    2. Great advice, gentlemen, thank you.

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  4. One witness who made the 911 call after he saw the plane flip as it headed east ... “I saw the plane and saw that it wasn’t right. It was in the wrong position. I kept an eye on it, which was the longest seven seconds,” D’Agostino said. “It started off over there on the west and made its way east. It flipped a couple of times and then nose-dived.”
    Also, Nno mention the acfts AGL in the CFIs choice to return. "How high should you be before attempting to turn back to the airport if the engine dies? It depends on the aircraft and the circumstances. Tests conducted for a July 2002 AOPA Pilot article, “Engine Out!” found that a Cessna 172 requires nearly 500 feet of altitude to return to the runway using an aggressive 45-degree bank and allowing the nose to fall fairly dramatically through the turn in order to maintain airspeed. This test was conducted under ideal conditions and assumed only a four-second lag from the time the engine quit until the pilot took decisive action. For most of us, four seconds isn’t much time to overcome the shock and denial of becoming an impromptu glider pilot, especially if smoke and oil are pouring from the failed engine." @ featured-accidents/engine-failure-on-climbout-leads-to-impossible-turn

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  5. Unfortunately, our current instructor pool has been severely diluted with mediocracy.

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  6. Sounds like they should reopen the 2016 crash lawsuit that was dismissed in 2019

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    Replies
    1. They will need to wait for the FBI to wrap up the N15294 investigation first.

      https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/94182/pdf

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  7. If they had only flown a controlled forced landing into the marsh, they might have nosed over but had a decent chance of crawling out better than a stall/spin. Every single engine pilot - and instructor - should be prepared to accept this option.

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