Friday, March 19, 2021

Loss of Control in Flight: Commuter Craft Innovator, N257AR; fatal accident occurred March 23, 2019 near Tom B. David Airport (KCZL), Calhoun, Gordon County, Georgia

Richard Nolan Hogan
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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; Atlanta, Georgia
Continental Engines; Mobile, Alabama 

Investigation Docket - National Transportation Safety Board:


Location: Calhoun, Georgia
Accident Number: ERA19FA134
Date & Time: March 23, 2019, 15:35 Local
Registration: N257AR
Aircraft: HOGAN Innovator
Aircraft Damage: Substantial
Defining Event: Loss of control in flight 
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General aviation - Flight test

Analysis

The pilot, who was also the owner/designer/builder of the experimental amateur-built airplane, had no recent flight experience and a medical certificate that had expired about 20 years before the accident flight. Despite assurances to his employees that he would not fly the airplane on what was its second test flight, video from inside the accident airplane showed that the pilot departed on the accident flight and the airplane immediately displayed rapid divergences in both the pitch and roll axis that were demonstrated on the airplane's first test flight. The airplane remained at treetop height throughout the upwind leg and into the crosswind turn and reached about 200 ft above ground level in level flight on the downwind leg. As the airplane accelerated, rapid pitch oscillations (phugoid) were exhibited. A handheld radio secured to the copilot's seat shoulder harness and the pilot himself were seen to "float" in the cockpit each time the airplane pitched nose down as the amplitude of the phugoid progressively increased, the duration of weightlessness displayed each time also increased. During one phugoid, an audible "oil pressure" warning was heard. The video ended abruptly as the pilot became unseated for about the fourth time and as the airplane appeared near treetop height. The airplane then impacted terrain.

The pilot had no experience in the accident airplane, which was the prototype for an airplane he intended to mass produce. A test pilot had completed the airplane's first flight in the traffic pattern. He described significant stability issues, which were captured by onboard video, and said the airplane departed controlled flight uncommanded about a dozen times. After the test pilot was able to safely land the airplane, it was disassembled, returned to the factory, modified according to the accident pilot's specifications based on captured data and the test pilot's observations, and then brought back to the departure airport for taxi testing the day before the accident.

According to employees of the company, the pilot was pressured by investors and missed deadlines, and was sleep-deprived and ill from a "severe" cold for which he was self-medicating. This pressure likely influenced the pilot's decision to test the prototype airplane himself despite his lack of experience and the stability issues demonstrated by the airplane on its initial test flight.

Examination of the wreckage and aircraft data captured from avionics systems, as well as statements from witnesses confirmed that the engine operated smoothly and continuously through the end of the flight. The condition of the wreckage precluded a thorough accounting of the flight control system; though based on statements provided by the previous test pilot, it is likely that the stability portrayed in the video of the first test flight remained during the accident flight, and when combined with the pilot's lack of experience, resulted in him being unable to maintain control of the airplane.

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 aircraft control during the airplane's second test flight, which resulted in a collision with terrain. Contributing to the accident was the pilot allowing external pressures to guide his decision to fly the airplane when he possessed little total flight experience, no recent flight experience, and no experience in the accident airplane or similar airplane.

Findings

Aircraft Pitch control - Not attained/maintained
Personnel issues Aircraft control - Pilot
Environmental issues Financial pressure - Decision related to condition
Environmental issues Time/schedule pressure - Decision related to condition
Personnel issues Stress - Pilot
Personnel issues Total experience w/ equipment - Pilot
Personnel issues Recent experience - Pilot

Factual Information

History of Flight

Approach-VFR pattern downwind  Loss of control in flight (Defining event)

On March 23, 2019, at 1535 eastern daylight time, an experimental amateur-built Commuter Craft Innovator, N257AR, was destroyed by collision with terrain during an uncontrolled descent after takeoff from Thomas B. David Field (CZL), Calhoun, Georgia. The pilot/owner/designer/builder was fatally injured. Visual meteorological conditions prevailed, and no flight plan was filed for the flight test which was conducted under the provisions of 14 Code of Federal Regulations Part 91.

According to employees of Commuter Craft, the airplane was the prototype for an airplane planned for mass production. The airplane was flown for the first time by a test pilot on February 25, 2019 at Tom B. David Field (CLZ), Calhoun, Georgia. The test pilot completed one traffic pattern and landed. The airplane was disassembled, returned to the factory, modified according to the pilot/builder based on captured data and test-pilot observations, and then brought back to CLZ for taxi testing the day prior to the accident.

On the day of the accident, the pilot asked his assistant to fly in a "chase plane" with a camera and photograph the airplane "in case it takes off." The pilot said he did not intend to fly, would land if the airplane lifted off, and would only fly if "he had no other choice." According to his assistant, she watched from the chase plane as the airplane departed "barely above the trees," turned in the traffic pattern, and then descended from view.

According to the chase pilot, the pilot/owner instructed him to depart ahead of the accident airplane. The pilot/owner said he would take off, enter the downwind leg, "verify the plane was flying satisfactorily" and then climb the airplane to 3,000 ft. Once at altitude, the two planes would join up to capture footage of the prototype airplane in flight. Footage of the accident flight was not captured, but the pilot witnessed the accident flight from about 2,500 ft.

Video from a camera mounted on the airplane's right window show that, immediately after takeoff, the airplane displayed rapid divergences in both the pitch and roll axis and that the pilot made pronounced movements of the control stick in response. The airplane remained at treetop height throughout the upwind leg and into the crosswind turn and appeared to reach about 200 ft agl in level flight once established on the downwind leg. As the airplane accelerated, it showed rapid pitch oscillations and the amplitude of the pitch oscillations progressively increased. A handheld radio secured to the copilot's seat shoulder harness and the pilot himself were seen to "float" in the cockpit each time the airplane pitched nose down as the amplitude of the phugoid progressively increased, the duration of weightlessness displayed each time also increased.

Data recovered from an onboard recording device indicated the airplane experienced multiple pitch oscillations between about 1° nose down and 12° nose up. Engine parameters were nominal and show that the aircraft reached 100 percent power and stayed at a high-power setting until the end of the recording. During one pitch oscillation, an audible "oil pressure" warning was heard. The video ended abruptly as the pilot became unseated for about the fourth time and as the airplane appeared near treetop height. The airplane then impacted terrain.

The chase pilot watched the airplane take off and turn to the crosswind and downwind legs of the traffic pattern. He estimated the accident airplane never climbed more than 200 feet above ground level (agl), and that the airplane struggled "to maintain airspeed or a nose-up attitude." The chase pilot heard the pilot announce his intention to return to the airport, but that a reason was not specified. He said the airplane was "porpoising" in flight before the nose "dipped down" and the airplane collided with trees and terrain.

Another witness, who was also a pilot, watched the accident flight from his car as he approached the airport. The witness said that he saw the airplane, which he presumed had "just taken off," pitching and rolling about 20° left and right and nose-up and nose-down and that it appeared unstable. The witness described the crosswind turn as "steep" and estimated the bank angle at 45°. Another witness, who was inside his workshop when the airplane flew "low" overhead, said the sound of the engine was loud, smooth, and continuous until he heard the sound of impact.

Pilot Information

Certificate: Private 
Age: 62, Male
Airplane Rating(s): Single-engine land
Seat Occupied: Left
Other Aircraft Rating(s): None 
Restraint Used:
Instrument Rating(s): None 
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 3 Without waivers/limitations
Last FAA Medical Exam: December 6, 1999
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time: 334.7 hours (Total, all aircraft), 0.1 hours (Total, this make and model), 0 hours (Last 90 days, all aircraft), 0 hours (Last 30 days, all aircraft), 0 hours (Last 24 hours, all aircraft)

Review of Federal Aviation Administration records revealed the pilot did not hold a valid medical certificate and he had not completed a BasicMed course. A review of his logbook revealed the pilot had logged 334 total hours of flight experience.

Entries in the logbook began in 1986 and gaps of several years where the pilot logged no flights were noted. During 1986-1987, the pilot logged 40.6 hours of flight experience, then did not fly again until 1991. He flew regularly from 1991-1995 but did not fly again until 2011, where he logged only one flight. He logged 2 flights in 2017, and 3 flights in 2018.

The pilot logged 4.7 total hours of flight experience over the 3 flights in 2018. His most recent flight was 1.1 hours on April 27, 2018, in a Flight Design CTLS airplane. According to his employees and his logbook, the pilot had no experience in the Innovator airplane as either a pilot or passenger. Further, a review of the remarks section throughout his logbook revealed only rudimentary flights and flight training. The pilot had no experience as a test pilot and no such training reflected in his logbook.

According to two of the pilot's employees, the pilot discussed scheduling pressures regarding the development and fielding of the airplane. They each had conversations with the pilot about his role as designer/builder and the head of the company; they each strongly urged him to stay out of the cockpit of the accident airplane. The two employees sought and received assurances from the pilot that he would not fly the accident airplane. His executive assistant urged him to concentrate on running their operation
and reported financial pressures on the pilot from an investor.

When asked about the pilot's general health, two employees described the pilot as sleep deprived and that he was sick in the days preceding and on the day of the accident. His assistant said he had a "severe cough, head and chest congestion, and fever" and was self-medicating with over-the-counter "non-drowsy" cold medication.

Aircraft and Owner/Operator Information

Aircraft Make: HOGAN
Registration: N257AR
Model/Series: Innovator No Series 
Aircraft Category: Airplane
Year of Manufacture: 
Amateur Built: Yes
Airworthiness Certificate: Experimental (Special)
Serial Number: 002
Landing Gear Type: Tricycle
Seats: 2
Date/Type of Last Inspection: Condition 
Certified Max Gross Wt.:
Time Since Last Inspection: 
Engines: Reciprocating
Airframe Total Time: 
Engine Manufacturer: Continental
ELT: C126 installed, not activated 
Engine Model/Series: IOX-370-CLD1T
Registered Owner: 
Rated Power:
Operator: On file 
Operating Certificate(s) Held: None

The composite construction airplane was a two-place, twin-tailboom, rear-engine, pusher-propeller airplane, powered by a Titan IOX-370-CLD1T4 engine. According to a company employee, the airplane had accrued about 12 hours on the Hobbs meter, of which about 0.3 hours was actual flight time.

In a written statement, the pilot who performed the initial test flight of the accident airplane provided a detailed description of what he observed and experienced on that flight. He said:

As soon as I came off the ground the plane went into a wild oscillation of both pitch and roll. I ran out of elevator up trim within the first few seconds of that flight and then had a lot of control pressure involved to keep it flying around the pattern. At that point I realized I needed altitude to sort out the control ability of the aircraft… During the flight I actually bumped off the elevator stop at least three times. I don't know how many times during that flight the aircraft departed straight and level flight, all uncommanded, however I would guess it to be around a dozen times. At one point I considered bailing out of the plane but realized I had enough control to try to line up with the airport runway and attempt a controlled landing, or at least get it back to the airport where help could be given if the landing didn't go well. As it turned out once I reduced the throttle for the final approach I was able to let off some of my control pressure for the elevator and make a very nice controlled descent... In my opinion: the aircraft demonstrated a static stability that was divergent and unstable. While dynamic stability was just barely on the stable side of neutral. These two factors obviously fought each other in the stability of the aircraft.

Video of the first half of the test flight, which was captured by an onboard camera mounted on the copilot's window, provided a cross-cockpit view of the pilot and views outside his window and part of the windscreen. Audio of ambient noise in the cockpit as well as radio communications was heard throughout. The video viewed was consistent with the narrative description provided by the test pilot.
The camera's battery lost its charge mid-flight and the video ended abruptly on the upwind leg over the runway.

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual (VMC)
Condition of Light: Day
Observation Facility, Elevation: KRMG,644 ft msl
Distance from Accident Site: 12 Nautical Miles
Observation Time: 15:53 Local 
Direction from Accident Site: 239°
Lowest Cloud Condition: Clear 
Visibility: 10 miles
Lowest Ceiling: None 
Visibility (RVR):
Wind Speed/Gusts: 3 knots / 
Turbulence Type Forecast/Actual:  /
Wind Direction: 
Turbulence Severity Forecast/Actual:  /
Altimeter Setting: 30.2 inches Hg
Temperature/Dew Point: 21°C / -8°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Calhoun, GA (CZL)
Type of Flight Plan Filed: None
Destination: Calhoun, GA (CZL)
Type of Clearance: None
Departure Time: 15:33 Local 
Type of Airspace: Class G

Airport Information

Airport: TOM B DAVID FLD CZL 
Runway Surface Type: Asphalt
Airport Elevation: 655 ft msl
Runway Surface Condition: Rough; Vegetation
Runway Used: 35
IFR Approach: None
Runway Length/Width: 6034 ft / 100 ft
VFR Approach/Landing: None

Wreckage and Impact Information

Crew Injuries: 1 Fatal 
Aircraft Damage: Substantial
Passenger Injuries:
Aircraft Fire: None
Ground Injuries: N/A 
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 34.451389,-84.950836(est)

The airplane was destroyed by impact and displayed no evidence of pre- or post-impact fire. Ground scars and fragmentation of the wreckage were consistent with ground contact in a steep, nose-down attitude at high speed. The wreckage path was about 90 ft long and oriented 132° magnetic. The initial ground scar was in an open field and the main wreckage came to rest inside a narrow wood line between two fields. There was no evidence of fire. Flight control continuity could not be confirmed due to multiple cable breaks and fractures. All breaks and fractures exhibited signatures consistent with overload failure.

The engine was separated from its mounts and entangled with the main wreckage. Engine control continuity was established from the engine to its control quadrant, which remained attached to the engine. The two composite propeller blades of the contestant-speed propeller were both uniformly fractured at their respective hubs and displayed chordwise scratching.

The engine was rotated by hand at the propeller flange and powertrain continuity was confirmed through the accessory section. Thumb compression could not be confirmed on the #1 and #3 cylinders due to impact damage. Internal borescope examination revealed signatures consistent with normal wear and lubrication. The electronic magnetos were impact damaged, and the engine-driven fuel pump was
separated by impact.

Additional Information

The FAA issued Advisory Circular (AC) 90-89B, "Amateur-Built Aircraft and Ultralight Flight Testing Handbook," was issued to make amateur-built aircraft pilots aware that "test flying an aircraft is a critical undertaking," which should be approached with "thorough planning, skill, and common sense" and to provide recommendations and suggestions that could be combined with other sources on test flying (such as, the aircraft plan/kit manufacturer's flight testing instructions, other flight testing data) that would assist amateur owners to "develop a detailed flight test plan, tailored for their aircraft and resources."

The AC also provided guidance on developing a plan for each phase of an amateur-built airplane's production, including preparing for the airworthiness inspection, determining weight and balance, conducting taxi and flight testing, and developing emergency procedures. The suggested flight-testing regimen was separated into 10-hour segments for the 40-plus-hour flight testing requirement.

The AC also included guidelines for the experience level of the test pilot, which included, in part, the following:

The test pilot should be experienced and competent. He/she should have made a minimum of 100 solo flights in similar make, model, and type of ultralight and must follow the FLIGHT-TEST PLAN exactly. The FLIGHT-TEST PLAN aircraft and follow a flight-test plan that should examine the ultralight and its performance capability, beginning with the pre-flight inspection and ending only after the test pilot has explored the ultralight's published flight envelope as described in the flight manual.

The FAA issued AC 90-109A, "Transition to Unfamiliar Aircraft," which describes stability and controllability of unfamiliar aircraft:

7. Stability and Controllability, b. Discussion, (2) - Once the airplane is disturbed from its steady condition, dynamic stability comes into play. A positively stable airplane will return to its pre-disturbed flight condition upon removal of the disturbance. It might do this slowly or quickly, with or without oscillations.…. An airplane with negative dynamic stability will develop larger deviations from its original flight condition following a disturbance. Again, this can happen slowly or quickly, with or without oscillations. Obviously, an airplane with negative dynamic stability could be difficult, if not impossible, to fly.

(3) (a) Negative longitudinal dynamic stability (phugoid). If the airplane deviates slower (or faster) from its trimmed airspeed, it will accelerate (or decelerate) beyond its trimmed airspeed, then decelerate (or accelerate) again beyond its trimmed airspeed in ever-increasing airspeed and altitude deviations until it stalls, exceeds VNE [never-exceed speed], or impacts the ground. The pilot cannot rely on the airplane to self-correct even minor airspeed deviations caused by control input, wind gust, thermal activity, etc. This can result in fatigue, as the pilot must continuously suppress the excursions.

Medical and Pathological Information

The Georgia Bureau of Investigation, Division of Forensic Sciences, Decatur, Georgia, performed an autopsy of the pilot and determined the cause of death as multiple blunt force injuries.

The FAA Forensic Sciences Laboratory performed toxicological testing on the pilot. Testing revealed the presence of Ibuprofen, Naproxen, and Dextromethorphan in muscle tissue and Naproxen and Dextrorphan in liver tissue, but use of these medications would generally not present a hazard to aviation safety.




Aerial mosquito spraying draws fire from Salt Lake City west-siders, birders and environmentalists

Critics worry plan to have an Air Force C-130 help in the effort could do more harm than good.

Salt Lake City mosquito-control officials hoped to save some money when they sought free military assistance with their long-standing aerial-spray program over the soggy areas northwest of Utah’s largest metro area.

Now environmentalists, public health advocates, bird lovers and west-side organizers are urging them to shut down the spraying altogether, arguing that aerial applications may pose a far bigger threat than the pesky, blood-sucking insects the chemicals are intended to kill.

Streams of critics appeared Thursday at the monthly board meeting of the Salt Lake City Mosquito Abatement District. They highlighted the hazards of organophosphate insecticide to human and ecological health and the menace low-flying aircraft pose to the migratory birds that rely on this area for nesting habitat.

“The chemicals used also kill off nontarget species, especially other invertebrates that are important sources for foraging birds,” Salt Lake City resident Tena Rohr told the mosquito district board. “Insects and invertebrates are elemental in maintaining a healthy wetland food web. In this time of climate change and mass extinction, we don’t dare spray neurotoxins into our air.”

Spurring the controversy was the district’s proposal to enlist the Air Force to apply pesticide in September using a huge four-engine C-130 Hercules transport plane. The Air Force maintains a unit in Ohio dedicated to these types of missions as a way to provide training opportunities for pilots to fly at low altitudes.

The project area is 43,000 acres northwest of the Salt Lake City International Airport. These undeveloped lands are vital migratory bird habitat on the Great Salt Lake’s southeast shore and are the site of the new state prison and proposed inland port.

“We welcome the public to come to the meetings. We want to learn what their concerns are and do our best to address them so at the end of the day everyone is content with the outcome,” said board chairman Neil Vickers, a University of Utah biology professor, after the meeting. “The mosquito control people don’t want to be the bogey man in this situation. They are doing their best to provide the services they believe are appropriate and mandated in their charter.”

The district is accepting public comment through March 31. Its board will decide whether to use the Air Force at its April 22 meeting. But whatever the board decides, the district is expected to continue aerial spraying using private contractors flying small twin-engine planes.

The main reason for the spraying is to minimize the spread of West Nile and other viruses transmitted via mosquitos.

The mosquito district’s executive director, entomologist Ary Faraji, has spent much of the past month trying to convince community members that aerial spraying is safe. The low concentrations of pesticides and the timing of applications, he insists, would ensure human exposure and impact to nontarget insects and birds would be minimal.

Applications occur after sunset when pollinators and other nontarget insects and birds are not active. The aircraft release the pesticides at between 100 and 300 feet in elevation to minimize drift, according to an environmental assessment.

But Faraji’s message has not swayed Brian Moench, president of Utah Physicians for a Healthy Environment, Westside Coalition leader Richard Holman, Heather Dove, president of Great Salt Lake Audubon, and other prominent activists who denounced the spray program Thursday.

“These are heavy-lift aircraft. If you think you have a handle on drift, let me tell you, those four engines, to operate at the elevations that you’re suggesting, will be at maximum power, putting out maximum air,” Holman said. “If you think you’re controlling the drift of the toxins, you are not. They will be distributed far beyond your imagination.”

Holman fears spraying would disproportionately impact the already marginalized west-side communities that abut the treatment area.

“We must not allow a cure worse than the disease,” Moench added. “The incidence of severe outcomes from West Nile virus is so low that preventing those outcomes should not be allowed to eclipse the long list of health and environmental concerns from pesticide use.”

Opponents of the inland port see increased development on Salt Lake City’s northwest side driving the need for an escalation of the chemical war on mosquitoes — something one critic said would “negatively affect all life in the area, humans included.”

Moench, who called on the Utah Inland Port Authority Board in a separate meeting to disclose any contact it has had with the district about spraying for mosquitoes in the northwest quadrant, also argued that the insects pose an “unsolvable problem” in the area.

“Spraying does not reduce mosquito populations for more than a few days, and, in fact, it may be counterproductive long term, making the problem worse by creating mosquito resistance, wiping out mosquito predators, thereby increasing the mosquito population and even increasing the cases and severity of West Nile virus,” he said. “Regardless of the port, the mosquitoes basically will remain in that area as long as the Great Salt Lake wetlands are there.”

The project area encompasses three major bird preserves, including the 3,600-acre Gillmor Audubon Sanctuary. Dove was deeply incensed that the district’s environmental assessment did not devote a single word to the area’s global importance to migratory birds.

Gillmor Manager Ella Sorensen fears a low-flying C-130 would flush the birds, prompting them to abandon nesting sites and to expend energy they will need for their long journeys. A C-130 lacks the maneuverability of the smaller aircraft typically used, so the area impacted by the pesticide flights would be much larger if conducted by the Air Force.

“Birds commonly fly between sunset and dark. A noisy, [76,000-pound] aircraft flying at 300 feet with very large propellers right into the heart of the avian fly zone in sensitive wetlands habitat is not ecologically sensitive. It is inappropriate,” Sorensen said. “There will be disturbance of shorebirds in the peak migration period.”

Incident occurred March 19, 2021 at Chicago O'Hare International Airport (KORD), Illinois

CHICAGO, Illinois -- A small jet with a landing gear issue landed safely Friday morning at O'Hare International Airport.

The pilot of an Air Wisconsin regional jet requested to return to O'Hare for a "landing gear problem" shortly after departure, according to preliminary information from Federal Aviation Administration spokeswoman Elizabeth Cory.

The plane - destined for Destin-Fort Walton Beach Airport in Okaloosa County, Florida - landed without incident at O'Hare at 11 a.m., Cory said in an email. The jet initially took off from O'Hare at 9:47 a.m., she said.

Firefighters responded to the plane as a precaution, according to Chicago fire spokesman Larry Merritt. No one was transported to a hospital, he said.

Online flight records show the plane turned back to O'Hare when it reached downstate Danville, about 30 miles east of Champaign.

The plane was a twin-engine Canadair Regional Jet CRJ-200, according to online flight records. The business jet has 36 seats and was last produced in 2006.

Air Wisconsin Airlines flies planes exclusively as United Express in a partnership with United Airlines, according to the company's website.

The Chicago Department of Aviation and Air Wisconsin Airlines didn't immediately reply to requests for comment.

Fuel delivery issues cause flight delays at Sarasota/Bradenton International Airport (KSRQ)

SARASOTA, Florida (WWSB) - Several flights from Sarasota Bradenton International Airport were delayed Thursday because the airport ran out of jet fuel.

According to Fredrick Piccolo, CEO of the Airport Authority, fuel deliveries to the airport were late, which caused some flights to be delayed Thursday. “Given our tremendous increases in service, the fuel farm must be replenished daily,” he told ABC7.

Piccolo said general aviation companies on the airfield provided some fuel yesterday to help; and additional fuel tankers have been secured to relieve the current situation. “I understand the frustration of any passenger but we are moving as fast as possible and this was a rare occurrence,” he said.

The airport is currently expanding its fuel storage capacity by 200,00 gallons; the work is expected to be completed this summer.

Cessna A185F Skywagon 185, N2744Q: Accident occurred March 23, 2019 at Lafayette Regional Airport (KLFT), Louisiana

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; Baton Rouge, Louisiana


Location: Lafayette, LA 
Accident Number: CEN19LA108
Date & Time: March 23, 2019, 17:30 Local 
Registration: N2744Q
Aircraft: Cessna A185 
Injuries: 2 None
Flight Conducted Under: Part 91: General aviation - Personal

On March 23, 2019, about 1730 central daylight time, a Cessna 185 airplane, N2744Q, owned by a private individual experienced a brake anomaly after landing at Lafayette Regional Airport/Paul Fournet Field (LFT) in Lafayette, Louisiana. The two pilots on-board were not injured. The airplane sustained substantial damage to the left aileron and left-wing structure. The airplane was operated by the pilots as a 14 Code of Federal Regulations Part 91 personal flight. Day visual meteorological conditions prevailed and no flight plan was filed for the flight that originated at Baton Rouge Metropolitan Airport, Ryan Field (BTR) in Baton Rouge, Louisiana.

The second pilot flew most of the leg from BTR to LFT. He reported the taxi, preflight runup, takeoff and enroute flight were uneventful. The first pilot took the controls about 2 miles from LFT for landing. The first pilot stated the touchdown and rollout on runway 22 was "smooth," until the airplane was turning off the runway onto the taxiway. The right brake "grabbed very hard" causing the airplane to make a hard turn, about 180ยบ, and the left wing impacted the ground.

Aircraft and Owner/Operator Information

Aircraft Make: Cessna 
Registration: N2744Q
Model/Series: A185 F 
Aircraft Category: Airplane
Amateur Built: No
Operator: On file
Operating Certificate(s) Held: None
Operator Designator Code:

Meteorological Information and Flight Plan

Conditions at Accident Site: 
Condition of Light:
Observation Facility, Elevation:
Observation Time:
Distance from Accident Site:
Temperature/Dew Point:
Lowest Cloud Condition:
Wind Speed/Gusts, Direction: / ,
Lowest Ceiling:
Visibility:
Altimeter Setting: 
Type of Flight Plan Filed:
Departure Point:
Destination:

Wreckage and Impact Information

Crew Injuries: 2 None 
Aircraft Damage: Substantial
Passenger Injuries: 
Aircraft Fire: None
Ground Injuries: N/A 
Aircraft Explosion: None
Total Injuries: 2 None 
Latitude, Longitude: 30.24048,-91.9906 (est)

Aerodynamic Stall / Spin: Champion 7EC, N815PB; accident occurred March 24, 2019 in Fayetteville, Washington County, Arkansas






Aviation Accident Final Report - National Transportation Safety Board

Additional Participating Entity:

Federal Aviation Administration / Flight Standards District Office; Little Rock, Arkansas

Investigation Docket - National Transportation Safety Board:

Kerzen Properties LLC


Location: Fayetteville, AR
Accident Number: GAA19CA177
Date & Time: 03/24/2019, 1030 CDT
Registration: N815PB
Aircraft: Champion 7EC
Aircraft Damage: Substantial
Defining Event: Aerodynamic stall/spin
Injuries: 1 Minor
Flight Conducted Under: Part 91: General Aviation - Personal 

Analysis

The pilot of the float-equipped airplane reported that, during takeoff from a private lake, the float plane did not "climb as the day before." Upon reaching the end of the lake, he "pulled up hard" on the yoke to avoid power lines, but the "left wing [stalled]," and the float plane impacted the ground.

The float plane sustained substantial damage to both wings and the fuselage.

The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.

The pilot added that, about the time of the accident, the wind was from 190° at 12 knots, gusting to 21 knots. An automated weather observation station about 5 nautical miles from the accident site reported that, about the time of the accident, the wind was from 190° at 11 knots. The airplane departed the lake with a 180° heading.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's exceedance of the airplane's critical angle of attack during takeoff as he attempted to avoid power lines, which resulted in an aerodynamic stall. 

Findings

Aircraft Angle of attack - Capability exceeded
Personnel issues Aircraft control - Pilot
Environmental issues Wire - Contributed to outcome

Factual Information

History of Flight

Initial climb Abrupt maneuver
Initial climb Aerodynamic stall/spin (Defining event)
Initial climb Collision with terr/obj (non-CFIT)

Pilot Information

Certificate: Private
Age: 55, Male
Airplane Rating(s): Single-engine Land; Single-engine Sea
Seat Occupied:Front 
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present:No 
Instructor Rating(s):None 
Toxicology Performed: No
Medical Certification: Class 3 Without Waivers/Limitations
Last FAA Medical Exam: 10/05/2018
Occupational Pilot: No
Last Flight Review or Equivalent: 03/08/2019
Flight Time:  (Estimated) 1250 hours (Total, all aircraft), 25 hours (Total, this make and model), 1250 hours (Pilot In Command, all aircraft), 100 hours (Last 90 days, all aircraft), 30 hours (Last 30 days, all aircraft), 3 hours (Last 24 hours, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: Champion
Registration: N815PB
Model/Series: 7EC 453
Aircraft Category: Airplane
Year of Manufacture: 1956
Amateur Built:No 
Airworthiness Certificate: Normal
Serial Number: 7EC453
Landing Gear Type: Float; Tricycle
Seats: 2
Date/Type of Last Inspection: 03/16/2018, Annual
Certified Max Gross Wt.: 1474 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 6700 Hours as of last inspection
Engine Manufacturer: Lycoming
ELT: C91  installed, not activated
Engine Model/Series: N235-C1
Registered Owner: On file
Rated Power: 115 hp
Operator: On file
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KFYV, 1259 ft msl
Distance from Accident Site: 5 Nautical Miles
Observation Time: 1553 UTC
Direction from Accident Site:291° 
Lowest Cloud Condition:
Visibility:  10 Miles
Lowest Ceiling: Broken / 12 ft agl
Visibility (RVR):
Wind Speed/Gusts: 11 knots /
Turbulence Type Forecast/Actual: None / None
Wind Direction: 190°
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 30.04 inches Hg
Temperature/Dew Point: 16°C / 13°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Fayetteville, AR
Type of Flight Plan Filed: None
Destination: Fayetteville, AR
Type of Clearance: None
Departure Time: 1030 CDT
Type of Airspace: Class G

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: 35.980000, -94.070000 (est)

Aircraft Structural Failure: Pilatus PC-12/45, N944BT; accident occurred March 24, 2019 near Fort Lauderdale, Broward County, Florida





Aviation Accident Final Report - National Transportation Safety Board 

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

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Miramar, Florida
PPG; Huntsville, Alabama 

Investigation Docket - National Transportation Safety Board:


Location: FORT LAUDERDALE, Florida
Accident Number: ERA19LA137
Date & Time: March 24, 2019, 11:01 Local
Registration: N944BT
Aircraft: Pilatus PC12
Aircraft Damage: Substantial
Defining Event: Aircraft structural failure
Injuries: 3 None
Flight Conducted Under: Part 91: General aviation - Personal

Analysis

During the climb to cruise altitude on a cross-country flight, the pilot heard a loud bang and the pilot's side windshield shattered and the cabin began depressurizing. The pilot returned to the departure airport and landed uneventfully, where he noticed that the seal was extruded in two places around the outer pane. The windshield was sent to the manufacturer for a detailed examination, which revealed that 80% of the fiberglass straps were missing, and they were likely removed by maintenance personnel. A combination of missing straps and heavy delamination caused the outboard ply to become detached from the edge attachment. Moisture ingress at the bottom aft edge caused delamination and arcing. There was no record in the airframe logbook of the straps’ removal.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
Improper maintenance of the windshield, which resulted in delamination and in-flight depressurization.

Findings

Aircraft Flight compartment windows - Malfunction
Personnel issues Repair - Maintenance personnel

Factual Information

On March 24, 2019, about 1101 eastern daylight time, a Pilatus PC-12/45, N944BT, was substantially damaged when the pilot's windshield shattered while flying near Fort Lauderdale, Florida. The commercial pilot and two passengers were not injured. Visual meteorological conditions prevailed, and an instrument flight plan was filed for the flight that originated from the Fort Lauderdale Executive Airport (FXE), Fort Lauderdale, Florida, and was destined for Moore-Murrell Airport (MOR), Morristown, Tennessee. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.

According to the pilot, he was climbing through 20,000 ft when he heard a loud bang and the pilot-side windshield shattered. He immediately notified air traffic control that he was returning to FXE and needed to descend. After landing uneventfully, he examined the windshield and noticed that the seal was extruded in two places around the outer pane.

Examination of the airplane by a Federal Aviation Administration (FAA) inspector revealed that the pilot-side windshield was shattered but was still attached to the airplane. The bottom left corner and upper corner of the windshield were pushed outward, and the seal around the windshield was torn. The lower left heating element was burnt.

The windshield was sent to the manufacturer for further examination. The examination revealed that about 80% of the fiberglass straps were missing and had been removed by maintenance personnel. The missing straps caused the outboard ply to become detached from the edge attachment. Moisture was then able to ingress the bottom aft edge causing delamination and then allowing arcing to occur.

Investigators were unable to determine when these straps were removed, as there was no record of this maintenance in the airframe logbooks. The Pilatus Windows Inspection Check referred to the PPG service information letter which states specifically the straps should not be removed, rather repaired following their prescribed maintenance plan.

The pilot held a commercial pilot certificate with ratings for airplane single-engine land, single-engine sea, and multi-engine land. His most recent FAA third-class medical certificate was issued on November 15, 2017. He reported 9,000 total hours of flight experience, of which 2,600 hours were in the PC-12.

The airplane was manufactured in 2002. It was powered by a Pratt and Whitney PT6A-67, 1,250-horsepower engine, equipped with a four-bladed Hartzell propeller. Its most recent annual inspection was completed on January 15, 2019.

History of Flight

Enroute-climb to cruise Aircraft structural failure (Defining event)

Pilot Information

Certificate: Commercial; Flight instructor 
Age: 73,Male
Airplane Rating(s): Single-engine land; Single-engine sea; Multi-engine land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): Airplane 
Second Pilot Present: No
Instructor Rating(s): Airplane multi-engine; Airplane single-engine; Instrument airplane
Toxicology Performed: No
Medical Certification: Class 3 Without waivers/limitations
Last FAA Medical Exam: November 15, 2017
Occupational Pilot: No 
Last Flight Review or Equivalent: May 23, 2018
Flight Time: 9000 hours (Total, all aircraft), 2600 hours (Total, this make and model), 9000 hours (Pilot In Command, all aircraft), 30 hours (Last 90 days, all aircraft), 30 hours (Last 30 days, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: Pilatus
Registration: N944BT
Model/Series: PC12 45
Aircraft Category: Airplane
Year of Manufacture: 2002
Amateur Built: No
Airworthiness Certificate: Normal 
Serial Number: 468
Landing Gear Type: Retractable - Tricycle
Seats: 8
Date/Type of Last Inspection: January 15, 2019 Annual
Certified Max Gross Wt.: 9965 lbs
Time Since Last Inspection: 10 Hrs 
Engines: 1 Turbo prop
Airframe Total Time: 2558 Hrs at time of accident
Engine Manufacturer: Pratt & Whitney Canada
ELT: C126 installed, not activated 
Engine Model/Series: PT6A-67B
Registered Owner: 
Rated Power: 1250 Horsepower
Operator: On file 
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual (VMC) 
Condition of Light: Day
Observation Facility, Elevation: FXE,14 ft msl
Distance from Accident Site: 8 Nautical Miles
Observation Time: 11:00 Local 
Direction from Accident Site: 348°
Lowest Cloud Condition: Clear
Visibility: 10 miles
Lowest Ceiling: 
Visibility (RVR):
Wind Speed/Gusts: / 
Turbulence Type Forecast/Actual: /
Wind Direction: 
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 30.1 inches Hg 
Temperature/Dew Point: 24°C / 16°C
Precipitation and Obscuration:
Departure Point: Fort Lauderdale, FL (FXE)
Type of Flight Plan Filed: IFR
Destination: Morristown, TN (KMOR)
Type of Clearance: IFR
Departure Time: 10:00 Local 
Type of Airspace:

Wreckage and Impact Information

Crew Injuries: 1 None 
Aircraft Damage: Substantial
Passenger Injuries: 2 None 
Aircraft Fire: None
Ground Injuries: N/A 
Aircraft Explosion: None
Total Injuries: 3 None
Latitude, Longitude: 26.071388,-80.14167

Cessna 172RG Cutlass RG, N500DZ: Incident occurred March 18, 2021 in Atlanta, Georiga

Federal Aviation Administration / Flight Standards District Office; Atlanta, Georgia

Aircraft veered off runway during landing due to a crosswind. 

Charlie Kilo Delta LLC 


Date: 18-MAR-21
Time: 17:05:00Z
Regis#: N500DZ
Aircraft Make: CESSNA
Aircraft Model: 172
Event Type: INCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: UNKNOWN
Activity: PERSONAL
Flight Phase: LANDING (LDG)
Operation: 91
City: ATLANTA
State: GEORGIA

Beechcraft A23-B19 Sport 150, N1956W: Accident occurred March 19, 2021 at Joslin Field - Magic Valley Regional Airport (KTWF), Twin Falls, Idaho

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; Boise, Idaho


Location: Twin Falls, ID 
Accident Number: WPR21LA139
Date & Time: March 19, 2021, 00:30 Local 
Registration: N1956W
Aircraft: Beech B19
Injuries: 3 None
Flight Conducted Under: Part 91: General aviation - Personal

Aircraft and Owner/Operator Information

Aircraft Make: Beech
Registration: N1956W
Model/Series: B19 NO SERIES
Aircraft Category: Airplane
Amateur Built: No
Operator: On file
Operating Certificate(s) Held: None
Operator Designator Code:

Meteorological Information and Flight Plan

Conditions at Accident Site: VMC
Condition of Light: NightDark
Observation Facility, Elevation: TWF,4154 ft msl
Observation Time: 00:37 Local
Distance from Accident Site: 
Temperature/Dew Point: 11°C /-4°C
Lowest Cloud Condition: Clear 
Wind Speed/Gusts, Direction: 13 knots / , 190°
Lowest Ceiling: None
Visibility: 10 miles
Altimeter Setting: 29.97 inches Hg 
Type of Flight Plan Filed: None
Departure Point: Twin Falls, ID (TWF)
Destination: Spanish Fork, UT (SPK)

Wreckage and Impact Information

Crew Injuries: 1 None 
Aircraft Damage: Substantial
Passenger Injuries: 2 None 
Aircraft Fire: None
Ground Injuries: 
Aircraft Explosion: None
Total Injuries: 3 None 
Latitude, Longitude:  42.481806,-114.48775


TWIN FALLS, Idaho (KMVT/KSVT) —A family out of the McCall area is okay, after their plane crashed at Joslin Field Friday morning.

KMVT spoke to airport manager Bill Carberry, who said the call came in at 12:30 a.m. of a  Beechcraft A23-B19 Sport 150 aircraft crashing on Runway 8.

The plane was occupied by a father and his two sons when a strong windshear out of the south caused the plane to “pancake” into the runway.

Carberry said the plane got about 50 feet into the air before crashing and sliding approximately 300 feet.

At this time, the family is in good shape and crews are cleaning up debris and fuel in preparation for morning travel.

“Make sure we have all our pieces and parts put together here and there is some significant damage to the aircraft, so we want to make sure we have everything picked up and tucked away,” Carberry said.

The Twin Falls County Sheriff Department, Twin Falls Fire, and Police, as well as the Magic Valley Paramedics, responded to the scene.

The next flight is scheduled to leave at 6:35 a.m.

Piper PA-18-150, N82479: Accident occurred March 17, 2021 at Three Forks Airport (9S5), Gallatin County, Montana

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; Helena, Montana
Location: Three Forks, MT
Accident Number: WPR21LA137
Date & Time: March 17, 2021, 12:45 
Local Registration: 82479
Aircraft: Piper PA-18-150 
Injuries: 1 None
Flight Conducted Under: Part 91: General aviation - Personal

Aircraft and Owner/Operator Information

Aircraft Make: Piper
Registration: 82479
Model/Series: PA-18-150 
Aircraft Category: Airplane
Amateur Built: No
Operator: On file
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: BZN,4473 ft msl
Observation Time: 12:56 Local
Distance from Accident Site: 24 Nautical Miles 
Temperature/Dew Point: 11°C /-7°C
Lowest Cloud Condition: Clear
Wind Speed/Gusts, Direction: / ,
Lowest Ceiling: None 
Visibility: 10 miles
Altimeter Setting: 30.1 inches Hg
Type of Flight Plan Filed: None
Departure Point: Twin Bridges, MT (7S1)
Destination: Three Forks, MT (9S5)

Wreckage and Impact Information

Crew Injuries: 1 None 
Aircraft Damage: Substantial
Passenger Injuries: 
Aircraft Fire: None
Ground Injuries: 
Aircraft Explosion: None
Total Injuries: 1 None
Latitude, Longitude: 45.878388,-111.56889 

Cessna 182K Skylane, N2548R: Accident occurred March 18, 2021 at North Las Vegas Airport (KVGT), Clark County, Nevada

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; Las Vegas, Nevada Location: Las Vegas, NV
Accident Number: WPR21LA184
Date & Time: March 18, 2021, 16:00 Local 
Registration: N2548R
Aircraft: Cessna 182K 
Injuries: 1 None
Flight Conducted Under: Part 91: General aviation - Personal

On March 18, 2021, about 1600 Pacific standard time, a Cessna 182K airplane, N2548R, was substantially damaged when it was involved in an accident near Las Vegas, Nevada. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.

The pilot reported that prior to departure, he performed a preflight inspection of the airplane for the approximate 30 nm flight, at which time he observed 13 gallons in the left and right fuel tanks (totaling 26 gallons) using both a dipstick and the fuel quantity indicators. He did not notice any evidence of a fuel leak during his walkaround inspection of the airplane. After engine start, an engine run-up was accomplished, and the pilot departed the airport with the fuel selector in the BOTH position. At the time, the fuel quantity indicator showed that his fuel level was just below half full in each fuel tank.

About 7 minutes into the flight, the pilot observed the fuel gauges fluctuating between 1/4 and 3/8 full for both fuel tanks. The pilot reported that he was not concerned at the time as he was close to his destination. However, about 2 nm from his destination the pilot observed that the fuel level had dropped to below 1/4 in both fuel tanks. The pilot started his approach for his destination airport by following his pre-landing checklist. He subsequently received instruction from the airport traffic controller to land on runway 12R, but when he entered the airport traffic pattern, the pilot observed that the fuel quantity had further decreased. During his turn to the base leg of the traffic pattern, the engine experienced a total loss of power. The pilot notified the airport traffic controller of the power loss, and during the subsequent forced landing, the airplane landed hard in dirt about 700 ft short of runway 12R and came to
rest in the upright position.

The airplane’s fuselage was substantially damaged.

The airplane was retained for further examination. 

Aircraft and Owner/Operator Information

Aircraft Make: Cessna
Registration: N2548R
Model/Series: 182K 
Aircraft Category: Airplane
Amateur Built: No
Operator: On file
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: VGT,2205 ft msl 
Observation Time: 15:53 Local
Distance from Accident Site: 1 Nautical Miles
Temperature/Dew Point: 22°C /-4°C
Lowest Cloud Condition: Few / 12000 ft AGL 
Wind Speed/Gusts, Direction: 5 knots / ,
Lowest Ceiling: Non
e Visibility:
Altimeter Setting: 30.01 inches Hg
Type of Flight Plan Filed: None
Departure Point: Sandy Valley, NV (3L2)
Destination: Las Vegas, NV

Wreckage and Impact Information

Crew Injuries: 1 None
Aircraft Damage: Substantial
Passenger Injuries: 
Aircraft Fire: None
Ground Injuries: 
Aircraft Explosion: None
Total Injuries: 1 None
Latitude, Longitude: 36.216047,-115.20444 (est)

Globe GC-1B, N78096: Incident occurred March 18, 2021 in Houston, Texas

Federal Aviation Administration / Flight Standards District Office; Houston, Texas

Aircraft on takeoff roll swerved into a trench. 


Date: 18-MAR-21
Time: 16:02:00Z
Regis#: N78096
Aircraft Make: GLOBE
Aircraft Model: GC1B
Event Type: INCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: MINOR
Activity: PERSONAL
Flight Phase: TAKEOFF (TOF)
Operation: 91
City: HOUSTON
State: TEXAS