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General Aviation Reports - John Eakin

1. Accident Rpt WPR14CA125 02 04 2014 830 PST Regis N78330 Eastsound WA Apt Orcas Island ORS Acft Mk MdI CESSNA 172K Acft SN 17257567 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING 0 320 SERIES AcftTT 4230 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name GORDON BANRY Opr dba Aircraft Fire NONE Narrative The pilot reported that during landing the airplane encountered a wind gust landed hard and bounced several times The nose gear collapsed and the airplane skidded to a stop which resulted in substantial damage to the engine firewall The pilot reported no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 16 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt WPR14CA074 12 23 2013 1530 PST Regis N80238 Fullerton CA Apt Fullerton Muni FUL Acft Mk Mdl CESSNA 172M M Acft SN 17266466 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING 0 320 SERIES Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name FELLER GERALD A Opr dba Aircraft Fire NONE Summary The operator stated that the stud
2. Examination of the nose landing gear drag brace was performed by the NTSB Materials Laboratory located in Washington D C The results of the examination revealed the drag brace was fractured aft of the actuator attachment clevis The rod end fitting for the actuator was also fractured while the bearing end of the end fitting remained attached to the drag brace The fracture features of the rod end fitting were matte gray and rough consistent with ductile overstress fracture A portion of the fracture surface of the nose landing gear drag brace revealed the extent of the fatigue crack was approximately 40 percent of the cross section The fatigue features originated from the upper inboard comer which was in the area that was reworked during a repair made in July 2012 however no tightly curving crack arrest features consistent with an origin were observed adjacent to the surface The blend radius at the aft side of the lug measured 0 12 inch Additionally no evidence of paint was observed on the fracture surface A copy of the NTSB Materials Laboratory Factual Report is contained in the NTSB public docket A representative of the airplane manufacturer reported the date of manufacture of nose landing gear drag brace part number P N 5142002 5 could not be determined The representative also reported the part is not serialized at manufacture and the date and to whom the part was shipped after manufacture could not be determined According to the inform
3. The main wreckage came to rest nearly inverted in a field with the outer 3 foot section of the right wing and outer portion of the right flaperon separated Also located away from the main wreckage along an energy path were a wing inspection panel a hat splintered pieces of the propeller 2 pieces of ribs from the inboard section of the right wing and Dacron fabric covering There was no evidence of tree contact on the leading edge of the right wing nor on any of the observed components The horizontal and vertical stabilizers remained attached and all remaining flight control surfaces remained attached Extensive impact damage was noted to the left wing fuselage and cockpit The wreckage was recovered for further examination Examination of the elevator rudder and flaperon flight control system revealed no evidence of preimpact failure or malfunction Examination of the right wing revealed the main and aft spars fractured just outboard of the lift strut attach point Closely matching the fracture surfaces of the main and aft spars but not allowing them to touch revealed the outer portion of the right wing was displaced up approximately 45 degrees Additionally the main spar of the right flaperon was displaced up about 7 degrees beginning at a splice joint and the inboard hinge of the flaperon was bent up approximately 30 degrees The fracture surfaces of the main and aft spars of the right wing were labeled as to location and direction and were c
4. The pilot reported that he thought he may have inadvertently applied minor application of the right brake due to his foot placement The pilot reported no mechanical malfunctions or failures with the airplane that would have precluded normal operation Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 104 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt ERA14CA201 04 12 2014 0 Regis N2297L Blountstown FL Acft Mk MdI WSK PZL MIELEC M 18A Acft Dmg Rpt Status Prelim Prob Caus Pending Fatal 0 Serinj 0 Opr Name Opr dba Aircraft Fire Printed May 22 2014 an airsafety com e product 7 7 Copyright 1999 2072 Air Data Research Page 105 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com
5. Midair collision 2 Emergency descent Collision with terr obj non CFIT Findings Cause Factor 1 Personnel issues Psychological Attention monitoring Monitoring other aircraft Pilot C 2 Personnel issues Action decision Action Lack of action ATC personnel F Narrative HISTORY OF FLIGHT On February 19 2012 about 1845 Pacific standard time a Beech 35 A33 airplane N433JC and a Robinson R22 Beta helicopter N7508Y collided midair near Antioch Califomia The airplane was owned and operated by the private pilot under the provisions of Title 14 Code of Federal Regulations CFR Part 91 as a local flight The helicopter was registered to Spitzer Helicopter Leasing Company and operated by the commercial pilot under the provisions of Title 14 CFR Part 91 as a solo cross country flight in preparation for obtaining her helicopter rating None of the aircraft occupants were injured The helicopter was receiving flight following at the time of the accident and departed Hayward Executive Airport Hayward California about 1815 with a planned destination of Sacramento Executive Airport Sacramento Califomia The airplane departed Byron Airport Byron Califomia about 1835 Night visual meteorological conditions prevailed and neither aircraft filed a flight plan The airplane pilot stated that he performed an uneventful preflight inspection during which he confirmed all lights were operational They departed Byron with Printed May 22 2014 an
6. Accident Rpt WPR13LA295 06 27 2013 1930 Regis N7187B Fielding UT Apt N a Acft Mk Mdl ROBINSON HELICOPTER R44 ASTRO Acft SN 0517 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING 0 540 SERIES AcftTT 3085 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name WHIRLYBIRD HELICOPTERS Opr dba Aircraft Fire NONE Narrative On June 27 2013 about 1930 mountain daylight time a Robinson R44 helicopter N7187B was substantially damaged following impact with terrain while maneuvering near Fielding Utah The student pilot the sole occupant of the helicopter was not injured The helicopter was registered to AMW Aerospace LLC and operated by Whirlybird Helicopters located in Ogden Utah The instructional flight was conducted in accordance with 14 Code of Federal Regulations Part 91 Visual meteorological conditions prevailed for the flight and a flight plan was not filed The helicopter departed the Brigham City Airport BMC Brigham City Utah about 1830 with its destination being Ogden Hinckley Airport OGD Ogden Utah In a statement submitted to the National Transportation Safety Board NTSB investigator in charge IIC the 44 hour student pilot reported that as he entered a canyon he climbed to about 5 600 feet mean sea level msl which was 100 feet above his profile altitude of 5 500 feet msl Upon entering the mouth of the canyon he slowed to between 70 to 75 knots as there had been turbulence going throu
7. FAA inspector revealed that the airplane nosed over The flaps were fully retracted and flight control continuity was confirmed According to The Flight Instructor s Manual Third Edition by William K Kershner Shooting Take and Solo states in part Never have the student shoot touch and go s on the first solo A review of the student pilot s logbook revealed a total of 14 entries that began on May 13 2013 and ended on June 10 2013 The total flight time was 12 5 hours excluding the accident flight The fifth entry was dated May 18 2013 which was preceded by an entry dated May 23 2013 The May 18 2013 entry Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 12 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database was the first entry that cited takeoff and landings and was followed by eight subsequent entries for takeoff and landings The logbook entries did not cite all of the pre solo maneuvers that the student pilot was required to have received instruction under Part 61 87 Solo Requirements for Student Pilots The maneuvers procedures in Part 61 87 include 1 Proper flight preparation procedures including preflight planning and preparation powerplant operation and aircraft system
8. Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com Page 11 National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt CEN13LA342 06 10 2013 800 CDT Regis N6412G Morrilton AR Apt Morrilton Municipal Airport BDQ Acft Mk Mdl CESSNA 150K Acft SN 15071912 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl CONTINENTAL O 200A AcftTT 2672 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name FLIGHT INSTRUCTOR Opr dba Aircraft Fire NONE Narrative On June 10 2013 about 0800 central daylight time a Cessna 150K N6412G nosed over and impacted terrain during landing on runway 27 at Morrilton Municipal Airport BDQ Morrilton Arkansas The airplane veered off the left side of the runway while the student pilot was attempting a touch and go landing during a first solo flight The flight instructor told the student pilot to perform the touch and go landings instead of full stop landings The airplane sustained substantial damage to the empennage The student pilot received minor injuries The airplane was registered to and operated by the flight instructor under 14 Code of Federal Regulations Part 91 as an instructional flight that was not operating on a flight plan Visual meteorological conditions prevailed for the local flight that originated from BDQ about 0730 The student pilot stated that she studied Gleim FAA Test Preparation since her first flight and belie
9. Pending Eng Mk Mdl LYCOMING 0 320 E2D Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name ROBERT I GOODWIN Opr dba Aircraft Fire NONE Summary The pilot said he was attempting to land on runway 18 in variable crosswinds with gusty conditions There may have been wind shear or tailwinds involved He said the airplane stalled at low altitude 5 to 8 feet above the runway and landed hard on the overrun for runway 36 The pilot reported no mechanical issues with the airplane The fuselage was buckled the empennage was bent down and the left wing upper skin was deformed Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS An inadvertent stall during gust crosswind conditions Events 1 Approach VFR pattem final Loss of control in flight 2 Uncontrolled descent Collision with terr obj non CFIT Findings Cause Factor 1 Personnel issues Action decision Action Delayed action Pilot C 2 Environmental issues Conditions weather phenomena Wind Crosswind Contributed to outcome 3 Environmental issues Conditions weather phenomena Wind Gusts Contributed to outcome Narrative The pilot said he was attempting to land on runway 18 in variable crosswinds with gusty conditions There may have been wind shear or tailwinds involved He told a Federal Aviation Administration FAA inspector that the airplane stalled at low altitude 5 to 8 feet above the runway and landed hard on th
10. There were impact marks on the hub from the pitch horn boot and impact marks from the pitch horn to the hub leading edge face with the leading edge 60 degrees upward from normal orientation The spindle was tom and there was deformation of the leading edge of the spindle bolt hole There was a fracture from the leading edge aft to 2 7 inches with the aft face having a joumal impression The pitch horn was fractured and deformed with impact marks immediately adjacent to the fracture surface The pitch change link assembly remained attached to the pitch horn by the appropriate hardware There was a torque stripe on one side of the pal nut The rod end at the opposite end of the link assembly was unremarkable The blade was cut 13 feet 7 inches inboard of the rotor tip for recovery The spindle was connected and rotated roughly The blue main rotor blade exhibited thermal damage from the hub outward about 8 feet towards the rotor tip and the entire blade was bowed down The data plate was found installed on the blade as number 3034 Blade delamination was consistent with thermal damage There was impact damage 4 feet 6 inches 6 feet 6 inches and 10 feet 10 inches from the blade tip The blade was cut 13 feet inboard of the rotor tip for recovery The blade tip cover and weight was in place with no chord wise scoring noted from the tip inboard on the lower surface There was compression wrinkles on the lower surface 1 foot 7 inches inboard from the rotor tip Th
11. com e product Copyright 1999 2012 Air Data Research Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com Page 5 National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt ERA14CA213 04 29 2014 1342EDT Regis N6756X Fort Pierce FL Apt St Lucie County International FPR Acft Mk Mdl BEECH 76 Acft SN ME 346 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING LO 360 AcftTT 12489 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name ARI BEN AVIATOR INC Opr dba AVIATOR COLLEGE OF AERONAUTICAL Aircraft Fire NONE SCIENCE amp TECHNOLO AW Cert STN Summary The instructor of the multiengine airplane reported that he and the student pilot had intentionally shutdown and secured the right engine for training purposes however they were unable to get it restarted The instructor then flew the airplane back to the departure airport and extended the landing gear while on a 2 mile left base leg of the airport traffic pattern for runway 14 After the landing gear was extended the instructor noticed a high descent rate and subsequently raised the landing gear which arrested the descent At that point the tower controller reported that the wind was from 130 degrees at 20 knots gusting to 35 knots The instructor extended the landing gear again when the airplane was es
12. 4 span The blades were removed from the hub and all three pitch change links were fractured and the fracture features were consistent with overstress No other internal components exhibited damage A liquid consistent with water along with oil was present when the piston assembly was removed from the cylinder The govemor part number DC290 D1F T8 serial number 051824 was missing four of its cap screws Oil drained from the govemor did not contain liquid consistent with water Four cap screws were installed onto the governor in preparation for a bench test The test results indicated that the maximum govemor speed was 2 350 rpm specification limit was 2 275 rpm The pressure relief valve regulated pressure to 305 psi Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 31 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Flow testing of govemor revealed an input oil pressure of 50 psi and an output oil pressure of 124 psi The flow value was 5 9 quarts minute minimum limit was 5 0 quarts minute no maximum limit value An internal leakage rate test revealed the leakage rate was 2 quarts hour maximum limit was about 10 quarts hour On March 6 2013 the NTSB Investigator In Charge presented questio
13. 6347 Fatal 1 Serlnj 0 Fit Conducted Under FAR 091 Opr Name RAY VEATCH AGENCY INC Opr dba Aircraft Fire NONE Narrative HISTORY OF FLIGHT On November 29 2013 about 0750 mountain standard time a Cessna 182E airplane N3087Y impacted terrain near Delta Colorado The student pilot the sole occupant was fatally injured and the airplane was destroyed The airplane was registered to Ray Veatsch Agency Inc and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as an instructional flight Day instrument meteorological conditions existed at the time of the accident and no flight plan was filed The flight departed from Blake Field Airport KAJZ Delta Colorado at 0748 and was destined for Crawford Airport 99V Crawford Colorado The student pilot scheduled his private pilot practical test with a designated examiner DE located at 99V about 20 nautical miles east of KAJZ According to the DE the student pilot called him on the morning of the accident and informed him there was a cloud deck at KAJZ The DE told the student pilot the cloud deck was likely a thin layer that would burn off and to fly to 99V after the weather cleared up An airport surveillance camera captured the accident airplane departing from Runway 3 at KAJZ No witnesses observed the accident PERSONNEL INFORMATION The student pilot age 36 had accumulated a total of 98 flight hours including 63 hours with a flight instructor and 6 4 hours
14. AND RESEARCH Several components from the rotor head system were harvested from the wreckage and sent to the NTSB Materials Laboratory in Washington D C for further examination The examination revealed that all fractures were consisted with overstress and no preexisting cracking was noted The examination also revealed that the pitch change link attachment hole for the red blade appeared intact free of damage and was covered with black sooty deposits The pitch link attachment hardware was missing from the attachment to the red blade side of the swash plate A detailed report of the examination is contained in the NTSB public docket ADDITIONAL INFORMATION According to a pilot rated witness who was at the hangar during the maintenance procedure the pilot was upset during the course of the day The pilot had conducted conversations with the helicopter manufacturer over the installation of the refurbished spindles that were installed on the new blades and that it was costing him 10 000 a month in lost revenues due to the helicopter not being in service The pilot witness who had flown the helicopter numerous times stated that he observed the mechanic make adjustments to the pitch change rods on the rotor system during the maintenance procedure He also stated that the mechanic told him that the owner of the helicopter was upset that the helicopter manufacturer installed refurbished spindles onto the new blades Printed May 22 2014 an airsafety
15. Cape Air as Flight 775 experienced collapse of the nose landing gear during the landing roll at Nantucket Memorial Airport ACK Nantucket Massachusetts Visual meteorological conditions prevailed at the time and a visual flight rules flight plan was filed for the 14 Code of Federal Regulations CFR Part 135 scheduled domestic passenger flight from Bamstable Municipal Airport Boardman Polando Field HYA Hyannis Massachusetts to ACK The airplane sustained minor damage and there were no injuries to the airline transport pilot or 9 passengers The flight originated from HYA about 1608 The pilot stated that on approach to ACK he extended the landing gears and performed the Before Landing Checklist with normal indications 3 Green no red no gear waming hom He landed on the main landing gears and as he lowered the nose it continued down until contact with the runway He notified air traffic control and evacuated the passengers Post incident inspection of the nose landing gear revealed the nose landing gear drag brace part number P N 5142002 5 was fractured near the actuator attachment lug Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 37 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database
16. Effect on operation 4 Environmental issues Conditions weather phenomena Wind Gusts Effect on operation Narrative The instructor of the multiengine airplane reported that he and the student pilot had intentionally shutdown and secured the right engine for training purposes however they were unable to get it restarted The instructor then flew the airplane back to the departure airport and extended the landing gear while on a 2 mile left base leg of the airport traffic pattern for runway 14 After the landing gear was extended the instructor noticed a high descent rate and subsequently raised the landing gear which arrested the descent At that point the tower controller reported that the wind was from 130 degrees at 20 knots gusting to 35 knots The instructor extended the landing gear again when the airplane was established on final approach at the proper glidepath but the descent rate again increased and the wind started to gust on short final approach The airplane subsequently touched down prior to the approach end of runway 14 in a grass drainage basin of a perpendicular runway During the landing the right wing struck the ground and the nosegear collapsed before the airplane came to rest upright in the basin With the exception of the inability to restart the right engine the instructor did not report any preimpact mechanical malfunctions with the airplane Examination of the airplane by a Federal Aviation Administration inspector revealed subs
17. FAA inspectors examined the airplane on scene They observed a 5 gallon bucket under the left wing with about 1 2 inch of fuel in it They opened the fuel caps on each wing tank but could not determine if any or how much fuel was in the tanks The FAA accident coordinator interviewed the pilot The pilot indicated that he was maintaining a low altitude to avoid the controlled airspace above him The pilot initiated a left tum to avoid rising terrain ahead and could not estimate the altitude above ground level agl The pilot did not think that winds were a factor but that the airplane might have been too low at the intuition of the turn The FAA accident coordinator interviewed the passenger The passenger stated that he was looking around enjoying the flight and the scenery as they were heading up a valley He did recall looking at the engine gauges as this time and the engine rpm was in the green operating range The engine sounded good up until the end As he looked back to the front of the airplane he and the pilot almost simultaneously stated that they were not going to make it The pilot indicated that they would be all right if they could get between two trees The airplane hit one of the trees and then the ground The passenger was not sure what direction the airplane was headed or if it was turning He felt that all changes to the airplane s flight path were controlled at all times and did not think that there were air pockets updrafts or dow
18. NONE Summary The pilot reported that he and his father had flown to the accident location to camp and hunt They made three passes over an open area to find a suitable landing spot The pilot stated that the grass appeared to be knee to hip height but he believed it was safe to land He set up for landing and on the landing rollout about 20 30 knots the left main landing gear wheel struck an unseen large embedded boulder that collapsed the left main landing gear The airplane s wing sustained substantial damage The pilot reported no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS The pilot s decision to land off airport on unsuitable terrain that resulted in a collision with hidden objects Events 1 Landing landing roll Collision with terr obj non CFIT 2 Landing landing roll Landing gear collapse Findings Cause Factor 1 Personnel issues Action decision Info processing decision Decision making judgment Pilot C 2 Environmental issues Physical environment Terrain Mountainous hilly terrain Contributed to outcome 3 Environmental issues Physical environment Object animal substance Hidden submerged object Contributed to outcome Narrative The pilot reported that he and his father had flown to the accident location to camp and hunt They made three passes over an op
19. Rpt Status Prelim Prob Caus Pending Fatal 0 Serlnj 0 Opr Name Opr dba Aircraft Fire Printed May 22 2014 an airsafety com e product 7 7 Copyright 1999 2072 Air Data Research Page 89 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt ERA12LA537 08 30 2012 1612EDT Regis N2481P Ocala FL Apt Nia Acft Mk Mdl QUAD CITY ULTRALIGHTS CHALLENGER Acft SN Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl ROTAX 503 Fatal 2 Serlnj 0 Fit Conducted Under FAR 091 Opr Name GILBERT C AND CATHERINE A Opr dba Aircraft Fire NONE JENNINGS Narrative HISTORY OF FLIGHT On August 30 2012 about 1612 eastern daylight time a Quad City Ultralights Challenger Il N2481P registered to and operated by a private individual crashed in a field surrounded by trees near Ocala Florida Visual meteorological conditions prevailed at the time and no flight plan was filed for the 14 Code of Federal Regulations CFR Part 91 personal flight from Morriston Florida to Leeward Air Ranch Airport FD04 Ocala Belleview Florida The airplane sustained substantial damage and the private pilot and one passenger were fatally injured The flight originated from Morriston Florida about 7 minutes earlier The purpose of the flig
20. SN 20700395 Acft Dmg SUBSTANTIAL Rpt Status Prelim Prob Caus Pending Eng Mk Mdl CONTINENTAL MOTORS INC Fatal 1 Serlnj 1 Fit Conducted Under FAR 091 Opr Name AMERICAN AVIATION INC Opr dba Aircraft Fire NONE Narrative On May 10 2014 about 1545 Mountain standard time a Cessna T207A N7311U was substantially damaged when it impacted terrain during landing at the Page Municipal Airport PGA Page Arizona The airplane was registered to and operated by American Aviation Page under the provisions of Title 14 Code of Federal Regulations Part 91 The airline transport pilot and four passengers sustained minor injuries one passenger sustained serious injuries and one passenger was fatally injured Visual meteorological conditions prevailed and a company flight plan was filed for the local sightseeing fight The flight originated from PGA about 20 minutes prior to the accident The pilot reported that about half way into a 40 minute sightseeing flight he noticed reduction in engine power Despite the pilot s attempts he was unable to correct the power reduction and initiated a tum towards the airport The pilot stated that he entered the airport traffic pattern for runway 15 about 1 000 feet above ground level and applied 10 degrees of flaps just prior to tuming base After tuming onto final for the runway the airplane suddenly descended abruptly impacted terrain and nosed over The pilot reported that he thought the airplane experienced a down
21. aeronautics offered both undergraduate and master s degree programs As part of these programs FIT Aviation LLC which was a wholly owned subsidiary of FIT provided both ground and flight training for FIT students and the general public under 14 CFR Part 141 ADDITIONAL INFORMATION Approximate Hours of Operation In 2012 the FIT aviation fleet of 45 airplanes accrued approximately 38 000 total hours of operation Including the PA 28 161s 42 of those airplanes incorporated a braking system similar to the accident airplane s braking system Each flew approximately 5 to 7 flights per day Review of the accident airplane s checklists revealed that the parking brake was being operated at least 6 times per flight which indicated that the parking brake was being operated on each airplane approximately 30 to 42 times per day Safety Actions In order to increase safety FIT Aviation took the following actions 1 FIT Aviation revised their Flight Operations Manual FOM to include a section on use of the parking brake and including expanded guidance on the use of the parking brake in the sections of the FOM concerning aircraft startup aircraft runup and aircraft parking FIT Aviation also added precautions in the FOM to not rely solely on the parking brake to keep the aircraft stationary with the engine running 2 FIT Aviation revised their lesson plans to include emphasis on not relying solely on the parking brake to keep the aircraft stationary wit
22. airplane came to rest in a gravel pit The pilot reported no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS The pilot s failure to maintain clearance from terrain Events 1 Enroute climb to cruise Controlled flight into terr obj CFIT Findings Cause Factor 1 Aircraft Aircraft oper perf capability Performance control parameters Altitude Not attained maintained C 2 Personnel issues Action decision Action Incorrect action performance Pilot C 3 Environmental issues Physical environment Terrain Mountainous hilly terrain Awareness of condition Narrative On July 5 2011 about 1050 Pacific daylight time a Grumman AA 5 N1334R collided with a tree and then terrain near Yacoit Washington The pilot owner was operating the airplane under the provisions of 14 Code of Federal Regulations CFR Part 91 The commercial pilot and one passenger sustained serious injuries the airplane sustained substantial damage from impact forces The personal cross country flight departed Grove Field Camas Washington about 1040 with a planned destination of Grant County Regional Ogilvie Field John Day Oregon Visual meteorological conditions prevailed and a visual flight rules VFR plan had been filed The pilot reported that he departed straight out from runway 25 and opened his fligh
23. always reported her correct call sign background noise and the inflection of her voice often resulted in the last digit yankee sometimes sounding like whiskey Airframe Examinations Postaccident examination of the airplane revealed that a forward portion of helicopter s right skid had become lodged in the leading edge of the right wing midspan A 6 inch long section of one propeller blade tip was missing and the spinner sustained crush damage and a black paint transfer next to the back plate During the forced landing the airplane sustained substantial damage to the wingtips firewall and the fuselage just aft of the left wing trailing edge The helicopter sustained damage during the collision sequence limited to the forward right skid and the center section of the left skid which was not recovered The helicopter did not sustain damage during the collision which would have prevented normal flight The helicopter rolled over during the landing most likely because of the separated landing gear skids As it rolled the tailcone came away from the fuselage and the forward cabin struck the ground The landing light switch was found in the OFF position following the accident and subsequent testing revealed that the lamp was operational The rear white and right green navigation lamps illuminated when tested however the left red lamp did not light Examination of the filament revealed that it had broken away completely at both posts Ad
24. and the west side of the fueling pad Fuel Sticks The fuel sticks used by EKU were purchased from a commercial manufacturer and were a combination of factory calibrated fuel sticks 19 gallons for the Cessna172Ps and 26 5 for all of the Cessna 172Rs and universal fuel sticks for all of the Cessna 172RGs and the Piper Seneca Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Prepared From Official Records of the NTSB By Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com Page 23 All Rights Reserved National Transportation Safety Board Aircraft Accident Incident Database During the investigation it was revealed that the fuel sticks did not have aircraft registration markings on them to determine if the correct fuel stick was onboard the correct aircraft and it was discovered that one of the airplanes in the fleet with 20 gallon tanks had a 26 5 gallon fuel stick in the cockpit ORGANIZATIONAL AND MANAGEMENT INFORMATION In 1984 EKU offered its first aviation courses and in 1989 was granted approval for a minor in aviation In 1991 EKU was approved to offer a baccalaureate degree program in aviation Students who earn their degree in professional flight also obtain a private pilot certificate commercial pilot certificate and an instrument rating They also can earn a flight instructor certificate with ratings for airplane sin
25. approach was too fast and too high so he performed a go around On the accident landing the airplane landed farther down the 2 610 foot runway than he anticipated The airplane did not slow down and as the end of the runway approached the pilot applied the brakes The airplane subsequently veered to the left and right and then back to the left again which allowed the right wing to contact the runway The nose of the airplane impacted a snow berm and the airplane came to rest inverted which resulted in substantial damage to the wing and fuselage An examination of the airplane revealed no mechanical malfunction or failure that would have precluded normal operation Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS The non certified pilot s failure to maintain a stabilized approach for landing that resulted in a long landing and subsequent runway overrun Events 1 Landing landing roll Loss of control on ground 2 Landing landing roll Runway excursion 3 Landing landing roll Collision with terr obj non CFIT Findings Cause Factor 1 Aircraft Aircraft oper perf capability Performance control parameters Descent approach glide path Not attained maintained C 2 Personnel issues Action decision Info processing decision Decision making judgment Pilot C Narrative During a pleasure flight the non certified pilot attempted twice to land at the accident airport On the first attem
26. at the time to be from 275 degrees at 15 knots with gusts to 25 knots The approach to landing was normal and the airplane touched down a little long past the numbers due to the tailwind A gust of wind then lifted the left wing high while he already had full left aileron controls in He added power while attempting to recover the left wing descended and the left main landing gear collapsed as the airplane landed hard The airplane ground looped around the failed gear and came to a stop An inspector with the Federal Aviation Administration responded to the accident site and inspected the wreckage He reported that the left main gear collapsed resulting in structural damage to the lower fuselage Structural damage was also observed on the left wing The pilot reported that the main gear safety cable failed and cut the landing gear bungees during the hard landing The safety cable was subsequently removed by the pilot and was forwarded to the NTSB Investigator in Charge for further examination Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 88 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt ERA14CA240 05 14 2014 0 Regis N32002 Norfolk VA Acft Mk Mdl PIPER PA28 151 Acft Dmg
27. at this moment that the pilot heard a thud According to local law enforcement personnel the pilot owner seated in the left front seat of the helicopter had just taken over from the pilot who was walking away from the helicopter when the accident occurred The pilot in the helicopter stated to local law enforcement immediately after the accident that he saw the previous pilot walking away thought he had walked beyond the main rotor blades and looked down to fasten his seatbelt While he was fastening his seatbelt he heard the main rotor blades strike something looked up and saw the relieved pilot on the ground The local law enforcement report stated that the relieved pilot was located between the 10 and 11 o clock position forward of the helicopter In addition the helipad was located in a level grassy area near the entrance to the fair grounds According to Federal Aviation Administration records the relieved pilot held a commercial pilot certificate for airplane single engine and multiengine land airplane single engine sea instrument airplane and helicopter glider and rotorcraft helicopter He reported on his last insurance application that he accumulated 3 900 hours of total flight time of which 600 hours were in the same make and model as the accident helicopter His most recent second class medical certificate was issued in December 2012 At that time the pilot reported a height of 71 inches According to the helicopter flight manu
28. attempted to land twice and aborted both landings due to the wind and terrain conditions The pilot briefed the passenger who was very familiar with balloon operations that they were going to make a high wind landing The passenger stated he crouched down in the basket for the landing and as the triangular basket touched down and turned to its flat side he felt his ankle roll The basket lay down and once the balloon stopped they crawled out of the basket The passenger stated he knew he injured his ankle and a couple days later he was diagnosed with a fractured tibia Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS An unexpected increase in wind velocity which resulted in a hard landing and the subsequent passenger injury Events 1 Enroute Other weather encounter 2 Landing flare touchdown Hard landing Findings Cause Factor 1 Environmental issues Conditions weather phenomena Wind High wind Effect on operation C Narrative The pilot reported the wind was from the north northwest at 6 knots when they departed and the balloon traveled to the southeast as expected When they descended to land the wind velocity increased to 20 plus knots and the wind changed 90 degrees in direction moving them to the west The pilot attempted to land twice and aborted both landings due to the wind and terrain conditions The pilot briefed the passenger who was very familiar with balloon operations t
29. by the Nichols Airborne Division Parker Hannifin Corporation stated that Airborne air pumps with any model number beginning with 200 through 216 must not be overhauled or repaired The service letter continued with the following caution SAFETY WARNING FAILURE OF AN OVERHAULED OR RECONDITIONED PARKER AIRBORNE PNEUMATIC COMPONENT ESPECIALLY WHILE FLYING IN INSTRUMENT METEOROLOGICAL CONDITIONS IMC CAN LEAD TO SPATIAL DISORIENTATION OF THE PILOT AND SUBSEQUENT LOSS OF AIRCRAFT CONTROL RESULTING IN DEATH BODILY INJURY OR PROPERTY DAMAGE OVERHAULED OR RECONDITIONED PARKER AIRBORNE PNEUMATIC COMPONENTS MUST NOT BE USED AND MUST BE REPLACED IMMEDIATELY Service Letter Number 72 issued on February 15 2008 by the Nichols Airborne Division Parker Hannifin Corporation stated All Parker Airborne Engine Driven Air Pumps are beyond their Mandatory Replacement time and must be removed from service Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 77 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt CEN14LA203 04 19 2014 1236EDT Regis N38240 Kalamazoo MI Apt Newman s Airport 4N0 Acft Mk Mdl PIPER PA 28 140 Acft SN 28 7725271 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus
30. com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database continued to tum left the altitude dropped during the next approximately 90 degrees of turn and at 1904 52 the glider was about 11 171 feet pressure altitude The calculated descent rate during this portion of the turn was 1 835 feet per minute The glider continued in the left tum and climbed back up during the next approximately 90 degrees of turn where it was about 11 414 feet pressure altitude at 1905 08 After this point the glider began a descending right tum During the next 21 seconds the glider s average rate of descent was calculated to be 2 437 feet per minute The glider then began an abrupt descent to the ground During the 59 second descent the gliders course varied but was predominately in an easterly direction The glider s average rate of descent was 4 044 feet per minute during this time period The pilot stated that the glider was in a right tum when the mishap occurred but the GPS data showed the glider in a left turn In subsequent telephone conversations the pilot could not explain why his recollection is different from the recorded data PERSONNEL INFORMATION The 68 year old pilot held a commercial pilot certificate with an airplane single engine land airplane multi engine land instrument airplane and glider ratings The pilot reported having 7 000 total flight hours including 100 hours in the accident glider He reported
31. days The flight instructor was unable to provide a flight instructor logbook during review by the FAA inspector The flight instructor last reported 27 110 hours of total flight time The total time of instruction given by the flight instructor was unknown because the flight instructor could not produce a flight instructor logbook In the last two years he endorsed three airman for a pilot certificate examination and those airman had a 100 percent pass rate These airman were examined by a designated pilot examiner DPE who became inactive on July 24 2012 The DPE s pass rate could not be determined Printed May 22 2014 an airsafety com e product Page 13 Prepared From Official Records of the NTSB By Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com Copyright 1999 2012 Air Data Research All Rights Reserved National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt WPR14CA075 12 24 2013 1330 MST Regis N5533B St Ignatius MT Apt St Ignatius 52S Acft Mk Mdl CESSNA 152 NO SERIES Acft SN 15283896 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING 0 235 SERIES Fatal 0 Serlnj 1 Fit Conducted Under FAR 091 Opr Name ROBERT WILLIAMS Opr dba Aircraft Fire NONE Summary During a pleasure flight the non certified pilot attempted twice to land at the accident airport On the first attempt the pilot stated that the
32. discovered that one of the airplane s occupants died at the scene and six others had survived the crash The six survivors were hoisted aboard the HH 60 helicopter and then transported to Petersburg During an interview with the National Transportation Safety Board NTSB investigator in charge IIC on June 6 the pilot stated that the accident flight was his fourth flight of the day and his third tour flight that day He said that weather conditions had deteriorated throughout the day with a ceiling of approximately 2 000 feet light rain and fog along the mountain ridges He had departed from the Petersburg harbor en route to LeConte Glacier via Horn Cliffs He reported that while approaching a mountain pass en route to LeConte Glacier he initiated a climb by adding a little bit of flap approximately 1 pump of the flap handle actuator but did not adjust the engine power from the cruise power setting He noted his airspeed at 80 knots with a 200 feet per minute climb on the vertical speed indicator He was having difficulty seeing over the cowling due to the nose high attitude as he entered the pass when he noticed trees in his flight path He initiated an immediate left hand turn the airplane stalled and began to drop impacting the mountainous terrain The pilot stated that there were no preaccident mechanical anomalies that would have precluded normal operation During a telephone conversation with the NTSB IIC on June 7 a passenger reported
33. during the three days preceding the accident All of the student s recorded flight time was in the accident airplane The student s recorded simulated instrument flight time was 0 6 hours The Federal Aviation Administration FAA requires 3 hours of simulated instrument flight training prior to the private pilot practical test On September 21 2011 the student pilot was issued a Class 3 medical and student pilot certificate with a limitation to wear corrective lenses No significant issues were identified by the pilot or aviation medical examiner during this examination AIRCRAFT INFORMATION The accident airplane was manufactured in 1962 and registered with the FAA ona standard airworthiness certificate The logbooks showed a total of 6 347 hours as of the last annual inspection which was conducted on November 12 2012 The airplane was equipped with a Continental Motors O 470 R engine serial number 131740 5 R which had accumulated a total of 2 895 hours as of the last annual inspection and 1 853 hours since last major overhaul The propeller was installed on September 1 2000 with no maintenance entries in the propeller log since installation METEOROLOGICAL INFORMATION The weather observation station at KAJZ reported the following conditions at 0755 wind calm visibility 4 miles overcast clouds at 600 feet temperature 0 degrees Celsius C dew point negative 1 degrees C altimeter setting 30 39 WRECKAGE AND IMPACT INFORMATION Th
34. e product Copyright 1999 2012 Air Data Research Page 42 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt WPR11LA311 07 05 2011 1900 PDT Regis N7392X Hesperia CA Apt Hesperia L26 Acft Mk MdI CESSNA R182 Acft SN R18200096 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING 0 540 J3C5D AcftTT 4159 Fatal 0 SerlInj 0 Fit Conducted Under FAR 091 Opr Name CHRIS E WAGGENER Opr dba Aircraft Fire NONE Summary The airplane s engine stopped making sufficient power to maintain a climb so the pilot decided to turn back toward the airport However after he flew into a valley he realized that the airplane would not make it back to the airport After seeing power lines along the airplane s flightpath he tumed the airplane toward an open field The airplane subsequently hit the ground hard and then hit a tree which separated the right wing from the airframe During the postaccident engine examination the muffler was disassembled One intemal baffle cone was found separated from the end plate and was blocking the opening of the muffler Upon shaking the muffler the baffle cone was free to move around within the muffler assembly The other baffle cone had a hole eroded in its center Internal engine fai
35. first and upon reaching 2 000 landings or for drag braces with over 2 000 landings this inspection shall be repeated every 250 landings for drag braces that have been reworked to remove a crack per the requirements of this Service Bulletin On April 1 2009 Cessna Aircraft Company incorporated Supplemental Inspection Number 32 20 00 SI 32 20 00 into the maintenance manual The supplemental inspection pertained to the nose landing gear drag brace and specified a visual and Fluorescent Liquid Penetrant Inspection and if a repair for cracks s corrosion or damage is required for a repair that is not available in the Model 402C maintenance manual to contact Cessna Customer Service for possible repair instructions or replace the part On September 30 2011 SI 32 20 00 was revised indicating that the required inspection method of the nose landing gear drag braces is visual and eddy current that repairs or modification of cracked nose landing gear drag braces was not allowed and the document supersedes MEB91 11 The operator did not incorporate SI 32 22 00 into their maintenance program and were not complying with it therefore they were still complying with MEB91 11R1 at the time of the incident A review of FAA Service Difficult Reports SDR s pertaining to nose landing gear drag brace P N 5142002 5 revealed that from 1995 to March 12 2014 excluding the SDR submitted for the incident event there were a total of 13 reported issues involving either cr
36. for flight were accounted for at the accident site The airplane was recovered to a secured storage facility for further examination At 0835 the SGU automated weather reporting facility located 10 nm east southeast of the accident site reported wind calm visibility 10 miles overcast clouds at 8 000 feet temperature 13 degrees Celsius C dew point 0 degrees C and an altimeter reading of 29 75 inches of mercury Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 10 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt WPR12LA430 09 17 2012 1030 PDT Regis N8130F Snohomish WA Apt Harvey Field Airport 43 Acft Mk Mdl CESSNA 150F Acft SN 15064230 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl CONT MOTOR O 200 SERIES Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name STEVENSON LARRY A Opr dba Aircraft Fire NONE Narrative On September 17 2012 about 1030 Pacific daylight time a Cessna 150F airplane N8130F sustained substantial damage after it collided with a fence during the landing roll at Harvey Field Airport Snohomish Washington The private pilot the sole occupant of the airplane sustained minor injuries The airplane was registered to
37. fraying or corrosion that remained after the cleaning was cause for replacement Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 87 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt ERA14LA103 01 18 2014 1200 EST Regis N3668N Zephyrhills FL Apt Zephyrhills Muni ZPH Acft Mk Mdl PIPER PA12 Acft SN 12 1919 Acft Dmg SUBSTANTIAL Rpt Status Prelim Prob Caus Pending Eng Mk Mdl LYCOMING 0 320 SERIES AcftTT 1282 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name CONNORS SEAN P Opr dba Aircraft Fire NONE Narrative On January 18 2014 about 1200 eastern standard time a Piper PA 12 N3668N was substantially damaged following a hard landing at Zephyrhills Municipal Airport ZPH Zephyrhills Florida The private pilot and one passenger were not injured The airplane was operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight Day visual meteorological conditions prevailed for the flight and no flight plan was filed The flight originated from Tampa North Aero Park X39 Tampa Florida about 1130 The pilot reported that he was number two of a formation flight of two and was landing on runway 4 He reported surface winds
38. he was talking about before the airplane departed 139 or after the forced landing the student pilot stated that he meant after the forced landing After being told that both fuel caps were found to be closed by the FAA when they arrived at the accident site he was asked if he knew who had reinstalled them and he said he did not know When asked if he remembered any low fuel annunciations from the annunciator panel he stated that he did not remember any When asked if the airplanes were parked with the fuel selector on BOTH he advised that they were Flight Instructor Interviews The flight instructor was asked how he knew that there was 20 gallons of fuel in each tank He stated that his student had stuck the tanks and had told him there was 20 gallons a side when he went out to the aircraft He was then asked if he had verified the quantity He said that when he got into the aircraft he noticed that the fuel gauges read 20 in one and 15 in the other He stated that he had performed a walk around and then got in the aircraft He also mentioned that he always watched his student do the entire preflight which is how he knows his student stuck the tanks He made a point to say that he always does this and doesn t do anything else when the student is preflighting the aircraft He was asked if he noticed if the fuel flow gauge had showed an increase in flow He said that it was reading normal around 10gph That is where we lean it to He was then asked if
39. impact damage from the upper wing skin which was consistent with a retracted flap position at the time of impact The flap control cables were secure to the bellcrank but the bellcrank was impact broken and the cables were pulled inboard The empennage section was found on top of the fuselage and displayed impact compression damage There were impact signatures consistent with ground impact most notably to the right side vertical stabilizer which also separated the right side of the stabilator The stabilator torque tube and hom assembly were in place and secure The balance tube was secure but displayed impact damage to the front end and the balance weight had been displaced to the aft The lower stabilator control cable had been impact separated from the attach fitting at the balance bar The upper stabilator control cable was secure to the balance bar Both stabilator cables were continuous to the forward cockpit area behind the instrument panels The right side of the stabilator was not identified at the crash site The stabilator trim drum upper extension measured about 0 6 inches which corresponds to a nose up setting of about 3 degrees of the available 13 degrees of nose up trim The fuselage was substantially compressed and fragmented The engine had penetrated aft into the forward cabin area and most of the cockpit instruments had extensive impact damage The flap handle was broken and bent The nose gear was in the retracted position The landi
40. loss of propeller control during cruise flight The pilot performed a forced landing on a highway after the airplane was unable to maintain altitude The airplane impacted power lines and terrain during a forced landing near Delta Colorado The airplane sustained substantial damage to the fuselage The private pilot was uninjured The airplane was registered to Janair LLC and operated by Colorado Flight Center under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight Visual meteorological conditions prevailed and a flight plan had not been filed for a local flight that originated from Grand Junction Regional Airport GJT Grand Junction Colorado at 1045 and was retuming to GUT The pilot stated that he performed touch and go landings at Montrose Regional Airport Montrose Colorado and was returning to GJT during the accident flight During the retum flight to GJT he reduced manifold pressure to 19 inches of mercury and began to reduce propeller speed from 2 400 rpm to 2 250 rpm shortly after the airplane leveled off at a cruise altitude of 8 000 feet mean sea level While adjusting propeller speed the propeller speed dropped abruptly to about 2 100 rpm while he was turning the propeller speed control knob He then pushed the propeller speed control knob full in but there was no change in propeller speed He then pushed the throttle control in to full power The airplane airspeed was about 110 knots indicated airspeed KIAS
41. of the data the exhaust gas temperature EGT values rose temporarily and then the EGT and cylinder head temperature values began rapid smooth and continuous decreases The temporary EGT rise preceding the decrease was consistent with engine shutdown by fuel starvation METEOROLOGICAL INFORMATION The 1355 automated weather observation at an airport located about 10 miles west southwest of the accident location included winds from 210 degrees at 9 knots visibility 10 miles clear skies temperature 17 degrees C dew point minus 12 degrees C and an altimeter setting of 30 07 inches of mercury WRECKAGE AND IMPACT INFORMATION The airplane came to rest inverted on the unpaved two track road that was used for the forced landing The cowl right wing strut vertical stabilizer and rudder were damaged by the nose over No fuel leaks were observed on site The four position LEFT RIGHT BOTH OFF fuel selector handle was found set to the left tank When the airplane was righted the day after the accident the left fuel tank was found to contain about 6 gallons and the right tank contained about 10 gallons The two wing tanks were interconnected with a vent line located near the top of the tanks which could permit fuel to migrate from the fuller tank to the other tank when the airplane was inverted ADDITIONAL INFORMATION According to the pilot s written statement regarding the accident just prior to the engine power loss the fuel flow device
42. on ground collision Events 1 Standing engine s operating Ground collision Findings Cause Factor 1 Personnel issues Task performance Use of equip info Use of equip system Pilot of other aircraft C 2 Personnel issues Action decision Action Incorrect action performance Pilot of other aircraft C 3 Personnel issues Psychological Attention monitoring Task monitoring vigilance Pilot of other aircraft C Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 81 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt ERA12LA355A 05 22 2012 2200 EDT Regis N47749 Melbourne FL Apt Melbourne International MLB Acft Mk Mdl PIPER PA 28 161 Acft SN 28 7816131 Acft Dmg MINOR Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING 0 320 D3G AcftTT 7174 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name FIT AVIATION LLC Opr dba Aircraft Fire NONE Summary The pilot of N602FT reported that while holding short of the runway waiting for departure he noticed another airplane stop behind his airplane A few seconds later the airplane was struck from behind by N47749 N602FT s position landing and strobe lights were illuminated when the accident occurred d The pilot of N4
43. on the fuel indicator and the amber annunciator would illuminate If the left tank transmitter failed the message would read L LOW FUEL If the right tank transmitter failed the message would read LOW FUEL R If both tank transmitters failed the message would read L LOW FUEL R Fuel System Limitations According to Cessna Aircraft to ensure maximum fuel capacity and minimize cross feeding when refueling the airplane should be parked in a wings level normal ground attitude with the fuel selector in the LEFT or RIGHT position and wamed that failure to operate the airplane in compliance with fuel Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 21 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database limitations may further reduce the amount of fuel available in flight Additionally they also advised that when securing the airplane the fuel selector valve should be placed in the LEFT or RIGHT position to prevent cross feeding Fueling Information According to the student that had flown the airplane on the flight before the accident flight during his preflight he noticed that the airplane only had 11 gallons of fuel onboard However before they departed he had the airplane fuele
44. personal local flight which had originated from Chelan about 20 minutes before the accident A flight plan had not been filed The pilot reported that after departure he climbed to about 5 000 feet when the airplane s engine suddenly stopped producing power He performed a forced landing to a road and the airplane s right wing impacted a power pole during the gear up landing The right wing s outer 4 feet was substantially damaged and nearly separated from the wing Postaccident examination of the airframe and engine by a Federal Aviation Administration inspector and an airframe and power plant mechanic revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 62 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt CEN14LA234 05 10 2014 1305CDT Regis N563JK San Antonio TX Apt Stinson Municipal Airport SSF Acft Mk MdI MOONEY AIRPLANE CO INC M20TN Acft SN 31 0107 Acft Dmg SUBSTANTIAL Rpt Status Prelim Prob Caus Pending Eng Mk Mdl CONT MOTOR TSIO 550 G Fatal 0 Serlnj 1 Fit Conducted Under FAR 091 Opr Name Opr dba Aircraft Fire NONE Narrative On May 10 2014 about 1305
45. pilot discovered that the flaps were fully retracted The airplane s manufacturer published a Pilot s Operating Handbook which states that after the throttle is moved to full power for a go around the wing flaps shall be retracted from 40 to 20 degrees The pilot stated that he had just purchased this particular airplane 4 days earlier He said he practiced two full stop landings and takeoffs but he did not practice any go arounds The pilot stated that the accident might have been avoided if he had practiced go arounds with incremental raising of the flaps or stopped the approach and exited the traffic pattern when he realized he was too high Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 30 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt CEN13LA258 05 02 2013 1127 Regis N2012Y Delta CO Apt Grand Junction Regional Airpor AJZ Acft Mk Mdl CESSNA 182T Acft SN 18281770 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING I0 540 AB1A5 AcftTT 1652 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name COLORADO FLIGHT CENTER Opr dba Aircraft Fire NONE Narrative On May 2 2013 at 1127 mountain daylight time a Cessna 182T N2012Y experienced a
46. seats were destroyed by postcrash fire The pilot and passenger restraints were cut to recover the victims and were intact before the postcrash fire ensued All restraint system hamesses were destroyed due to postcrash fire with the buckles fire damaged Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 94 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database The alternator was attached to the engine and fire damaged The alternator belt was consumed by fire The starter was fire and impact damaged and remained attached to the engine No vacuum pump was installed on the engine The magnetos and ignition harness were fire damaged The top and bottom spark plugs were removed and exhibited light gray combustion deposits and a normal wear condition with one covered in oil The engine was rotated by hand and compression and suction was noted on all cylinders Crankshaft and valve train continuity were confirmed to the rear gears All cylinders were examined using a lighted bore scope and no anomalies were noted The carburetor was destroyed by impact and fire The carburetor fuel inlet screen was removed fire damaged and absent of debris All fuel lines were fire damaged The fuel line between the fuel valve and g
47. she caught site of the silhouette of an airplane and propeller at her 4 o clock position She performed an evasive maneuver to the left and then felt the helicopter being struck She did not know the extent of the damage and elected to immediately perform a precautionary landing The area below was unlit and dark and she was aware that it included significant areas of water She therefore selected a road as her emergency landing spot During the approach she could see multiple automobiles and diverted to a spot adjacent to the highway She raised the collective control between 50 and 75 feet above ground level the helicopter landed hard and rolled onto its left side TESTS AND RESEARCH Radar and Audio Radar data and audio recordings for the accident were provided by the Federal Aviation Administration FAA and United States Air Force USAF and reviewed by an Air Traffic Control Specialist in the NTSB Operational Factors division A complete report is included in the public docket The data revealed that the pilot of helicopter N7508Y initially attempted to make contact with NORCAL approach about 1821 The controller did not reply and about 3 minutes later she made a second attempt The controller replied utilizing the incorrect call sign of Helicopter 7508W and the pilot utilizing the O8Y call sign requested flight following to Sacramento Executive Airport via Concord and Antioch The controller again responded with 08W and provided an alt
48. that they received a preflight safety briefing when they boarded the airplane After departure they headed out across the water towards LeConte Glacier He said that the airplane made a left turn stalled and then made a sharp left turn right before impact He said that the weather conditions at the time of the accident consisted of tufts of low clouds and good visibility They did not enter the clouds at any time during the flight He stated that the airplane seemed to be operating fine and he heard no unusual sounds other than the engine speed seemed to increase significantly just before impact Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 48 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database PERSONNEL INFORMATION The pilot age 39 held an airline transport pilot certificate with an airplane muilti engine land rating and commercial privileges for single engine land and single engine sea He also held a type rating for a Hawker Siddeley HS 125 airplane His most recent first class medical certificate was issued on April 24 2013 with the limitation not valid for any class after October 24 2013 According to the Pilot Operator Aircraft Accident Report NTSB Form 6120 1 submitted by the oper
49. the amount of air passing through the fuel air control unit Fuel Indicating Fuel quantity was measured by two float type fuel quantity transmitters one in each tank and indicated by an electrically operated fuel quantity indicator on the left side of the instrument panel The gauges were marked in gallons of fuel An empty tank was indicated by a red line and the number 0 When an indicator showed an empty tank approximately 1 5 gallons remained in each tank as unusable fuel According to Cessna Aircraft the indicators should not be relied upon for accurate readings during skids slips or unusual attitudes Each fuel tank also incorporated waming circuits which could detect low fuel conditions and erroneous transmitter messages Anytime fuel in the tank would drop below approximately 5 gallons and remained below this level for more than 60 seconds the amber LOW FUEL message would flash on the annunciator panel for approximately 10 seconds and then remain steady amber The annunciator could not be tumed off by the pilot If the left tank was low the message would read L LOW FUEL If the right tank was low the message would read LOW FUEL R In addition to low fuel annunciation the warning circuitry was designed to report failures with each transmitter caused by shorts opens or transmitter resistance If the circuitry detected any one of these conditions the fuel level indicator needle would go to the OFF position below the 0 mark
50. the cockpit area The wings were predominately intact The left wing had a split in the composite structure on the bottom skin that started from the joint between the removable wing tip running inboard The control system was intact except for a break in the right rudder cable at a point where the cable exited the forward exit of the S tube on the adjustable rudder pedals The rudder pedal assembly and cables were removed for further examination ADDITIONAL INFORMATION Examination of the design configuration revealed that the rudder pedals were mounted on the rudder pedal assembly by sliding the lower pivot tube of the pedal itself onto a smaller diameter tube on the adjustment assembly The pedal was retained laterally by a large diameter washer and a nut The retaining nut was an acorn style nut and did not have any internal locking capability nor was any other locking device installed Examination of the rudder pedal system from N555AP was conducted by the NTSB Materials Laboratory The right rudder cable was found to be severed at a location corresponding to the forward exit of the S tube on the adjustable rudder pedal assembly The cable was composed of 7 strands each of which had 19 wires Eleven 8 percent of the wires exhibited signatures consistent with overstress failure and the remaining wires 92 percent exhibited signatures consistent with fatigue failure due to bending stress The left rudder cable was also examined and 22 wires were
51. the horizon and provided no illumination A pilot report in the general area showed the reported cloud tops were as high as 12 000 feet msl with the dust tops to 12 000 feet msl A pilot operating his aircraft in the vicinity indicated that flight visibility was marginal at best and indicated that the area was impacted with blowing dust with an estimated in flight visibility of 1 to 3 miles The pilot indicated that he could only faintly see ground lights but at times could not distinguish between ground and sky A medical helicopter pilot operating in the area at the time of the accident reported that he was operating with his night vision goggles due to the dark nighttime conditions and that even with the night vision goggles the dust and lack of surface lights restricted his view of any sense of horizon and made flying under visual meteorological conditions very difficult COMMUNICATIONS AND RADAR Following is a timeline of selected communications between the pilot of N7147P and Federal Aviation Administration FAA Air Traffic Control ATC A summary of the FAA ATC radar contacts is included 1920 the controller cleared N7147P cleared for takeoff from runway 35L at ABI 1921 31 N7147P reported he was at 2 600 feet and was climbing to 9 500 feet 1931 38 radar showed N7147P was at a transponder reported altitude of 9 500 feet 1933 49 radar showed N7147P was at a transponder reported altitude of 9 700 feet and began a slight change in fligh
52. the pilot and operated as a visual flight rules VFR cross country flight under the provisions of 14 Code of Federal Regulations CFR Part 91 Visual meteorological conditions prevailed and no flight plan was filed for the flight that originated from Martin Field Airport College Place Washington about 3 hours and 30 minutes before the accident The pilot reported that when he applied wheel brakes during the landing roll the airplane veered left The airplane exited the hard surfaced runway and collided with a fence The pilot reported that after the accident he discovered a crack in the right brake hydraulic fluid line and that brake fluid was leaking from the crack Postaccident examination of the airplane s right side brake assembly and associated brake line by representatives from National Transportation Safety Board and the Federal Aviation Administration revealed 2 small cracks in the rigid portion of the hydraulic brake line The cracks were about 1 inch below a clamp that attached the hydraulic brake line to the gear leg Both cracks were seeping red fluid consistent with hydraulic fluid The exam also revealed structural damage to the right wing spar The pilot operator failed to submit a Pilot Operator Aircraft Accident Report NTSB Form 6120 1 2 Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View
53. the test pilot was still able to fully control the rudder if necessary during the flight test Since the accident pilot did not have knowledge of the nature of the control problem and did not have the ability to gain full rudder control his decision to bail out of the airplane was understandable Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS The fatigue failure of the rudder cable due to the inadequate design of the rudder pedal system Events 1 Enroute cruise Sys Comp malfffail non power Findings Cause Factor 1 Aircraft Aircraft systems Flight control system Rudder control system Failure C 2 Aircraft Aircraft systems Flight control system Rudder control system Design C Narrative HISTORY OF FLIGHT On April 29 2012 about 1300 mountain daylight time a Jonker Sailplanes model JS 1B glider NS55AP collided with terrain following an in flight loss of control near Clines Corner New Mexico The pilot bailed out of the glider and received minor injuries during his parachute landing The glider sustained damage to the fuselage and both wings The aircraft was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight Visual meteorological conditions prevailed for the flight which was not operated on a flight plan The flight originated from the Moriarty Airport 0E0 Moriarty New Mexico about 1230 The p
54. the total hours of operation of vacuum pump s n 1706 were estimated as about 636 hours for the period from January 21 2000 until October 19 2005 At the time of the accident N7147P had been operated an additional 3 2 hours following the engine installation on December 15 2011 This estimate was based on a review of the pilot s logbook which showed a flight of 1 4 hours on January 29 2012 a flight of 1 5 hours on February 1 2012 and an estimated 0 3 hours of operation during the accident flight on February 20 2014 At the time of the accident the airplane had an estimated aircraft total time of 4857 6 hours and vacuum pump s n 1706 had been operated for more than 12 calendar years and an estimated total of about 639 hours since overhaul The accident airplane was also equipped with an S TEC System 60 two axis autopilot with an optional electric pitch trim actuator and a vacuum driven attitude gyro and vacuum driven directional gyro METEOROLOGICAL INFORMATION At 1852 the automated weather observation station at ABI reported wind from 300 degrees at 12 knots visibility 3 miles in haze and blowing dust skies clear below 12 000 feet temperature 14 degrees Celsius C dew point temperature 11 degrees C altimeter 30 03 inches of Mercury Data from the United States Naval Observatory indicated that Sunset occurred at 1827 and Moonset occurred at 1734 At the time of the accident both the Sun and the Moon were more than 14 degrees below
55. there was a fluctuation in the Exhaust Gas Temperature EGT He advised that no the EGT was normal and that they had leaned the aircraft out in cruise to the needles on the EGT When asked when he noticed that there was a problem He said that on their way back to the airport he noticed that the fuel gauges were lower than normal About 5 to 6 miles north of the airport around 3000 feet above mean sea level msl the engine sputtered He stated that he took control of the aircraft and turned the fuel pump on enriched the mixture and the engine ran normally for about a minute He climbed to an altitude of about 3500 feet msl where the engine totally quit The propeller continued to windmill This occurred approximately 4 miles north of the airport He pitched for best glide speed of 65 knots indicated airspeed and attempted the restart procedure while turning directly towards the airport He noticed around 700 feet above ground level that he wasn t going to make the runway so he picked the field to make an emergency landing After discovering that a non approved checklist for the airplane was in the cockpit the flight instructor was asked what checklist he used for the engine failure He then mentioned that he always uses the pilot operating handbook POH as he doesn t trust anything but However when asked where the POH was located he stated that it was in the back of the airplane Printed May 22 2014 an airsafety com e product Copyright
56. travel forward rearward left and right The purpose of the cyclic pitch control is to tilt the tip path plane in the direction of the desired horizontal direction The cyclic controls the rotor disk tilt versus the horizon which directs the rotor disk thrust to enable the pilot to control the direction of travel of the helicopter The rotor disk tilts in the same direction the cyclic pitch control is moved If the cyclic is moved forward the rotor disk tilts forward if the cyclic is moved aft the disk tilts aft and so on Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 54 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt CEN14CA215 04 19 2014 815 MDT Regis N15095 Security CO Apt N a Acft Mk Mdl FIREFLY 8B 15 Acft SN F8B 2027 Acft Dmg NONE Rpt Status Factual Prob Caus Pending Fatal 0 Serlnj 1 Fit Conducted Under FAR 091 Opr Name HOWES SKIP Opr dba Aircraft Fire NONE Summary The pilot reported the wind was from the north northwest at 6 knots when they departed and the balloon traveled to the southeast as expected When they descended to land the wind velocity increased to 20 plus knots and the wind changed 90 degrees in direction moving them to the west The pilot
57. was performed in the hangar belonging to the mechanic with inspection authorization that certified the inspection He said that the mechanic was present while the inspection work was performed The airplane serial number 0048 was powered by a Lycoming O 320 A2B serial number L 49225 27A engine The airplane underwent an owner assisted annual inspection that was performed by the pilot The airplane logbook entry for the annual inspection was made by an airframe and powerplant mechanic with inspection authorization at American Aviation Inc Peyton Colorado and was dated April 2 2014 The entry stated Aircraft inspected IAW FAR 43 Appendix D Replaced vacuum regulator filter B3 5 1 Stop drilled 2 small cracks on top canopy Checked controls for travel and condition Checked sears belts and rails C W AD 72 06 02 on rudder and elevator control cables by inspection No broken strands noted C W AD 72 07 10 on elevator bungee by inspection C W AD 75 09 07 mixture control wire by inspection Replaced ELT Battery next change date March 2016 C W FAR 207D and checked good See owners entries for cowl wheels brakes tires etc Returned to service Applicable AD s thru 04 02 14 According to the Federal Aviation Administration inspector from the Denver Flight Standards District Office the logbook entry for the inspection was not in accordance with regulatory requirements because there were no additional entries relating to See owners entries for cow
58. 012 about 1845 Pacific standard time a Beech 35 A33 airplane N433JC and a Robinson R22 Beta helicopter N7508Y collided midair near Antioch Califomia The airplane was owned and operated by the private pilot under the provisions of Title 14 Code of Federal Regulations CFR Part 91 as a local flight The helicopter was registered to Spitzer Helicopter Leasing Company and operated by the commercial pilot under the provisions of Title 14 CFR Part 91 as a solo cross country flight in preparation for obtaining her helicopter rating None of the aircraft occupants were injured The helicopter was receiving flight following at the time of the accident and departed Hayward Executive Airport Hayward California about 1815 with a planned destination of Sacramento Executive Airport Sacramento Califomia The airplane departed Byron Airport Byron Califomia about 1835 Night visual meteorological conditions prevailed and neither aircraft filed a flight plan The airplane pilot stated that he performed an uneventful preflight inspection during which he confirmed all lights were operational They departed Byron with Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 96 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident D
59. 012 the nose landing gear drag brace was removed from the second airplane for inspection during which a 1 8 inch long shallow crack was found near the actuator attachment lugs The crack was blended in accordance with Cessna Service Bulletin MEB91 11 Revision 1 and then a fluorescent dye penetrant inspection of the area was performed The inspection did not detect any further cracks however it is likely that at this time some portion of the crack remained After the drag brace was retumed to service it was installed on the incident airplane on August 3 2012 Subsequently the nose landing gear drag brace was visually inspected in situ twice however neither inspection identified the fatigue crack o s At the time of the incident the airplane had been operated for about 286 cycles since the crack repair in July 2012 which exceeded the 250 cycle inspection interval specified by MEB91 11R1 It is likely that if the nose landing gear drag brace had been inspected after 250 landings in accordance with the manufacturer s service instructions the crack would have been detected at that time Additionally if the operator had incorporated into its maintenance program Supplemental Inspection 32 20 00 which stated in part that the nose landing gear drag braces should be inspected using visual and eddy current inspections and that repair or modification of cracked nose landing gear drag braces was not allowed it is likely that the nose landing gear drag b
60. 1553 weather observation located 1 5 miles west of the accident site reported wind from 120 degrees at 12 knots gusting to 18 knots visibility 10 statute miles scattered clouds at 3 000 feet above ground level temperature 29 degrees Celsius dew point 20 degrees Celsius and an altimeter setting of 30 00 inches of mercury Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 93 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database WRECKAGE AND IMPACT INFORMATION The helicopter was located upright in a parking lot on the comer of southwest 128th street and southwest 122nd avenue in Miami Florida and came to rest on a heading of 105 degrees magnetic M The debris field was 110 degrees at a distance of about 500 feet A postcrash fire had consumed a majority of the wreckage Several helicopter components were located on the roofs of several industrial buildings The red main rotor blade exhibited thermal damage about 7 feet from the hub outward towards the rotor tip and the entire blade was upside down The red main rotor blade data plate was missing and the alternate number was found on the inside of the tip cap as blade 3043 There was a paint scuff on the top surface of the spindle adjacent to the hub
61. 161 Acft SN 2841196 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING 0 320 D3G AcftTT 17077 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name F T AVIATION LLC Opr dba Aircraft Fire NONE Summary The pilot of N602FT reported that while holding short of the runway waiting for departure he noticed another airplane stop behind his airplane A few seconds later the airplane was struck from behind by N47749 N602FT s position landing and strobe lights were illuminated when the accident occurred d The pilot of N47749 reported that he was number three for departure behind N602FT While the pilot was looking at the tachometer the airplane slowly moved forward struck N602FT and severed the outer 2 feet of the left outboard portion of N602FT s horizontal stabilator The pilot realized after the collision that he had not set the parking brake He thought that his feet were on the brake pedals but that he did not put much pressure on them before the crash Postaccident examination of N47749 s brake system did not reveal evidence of any preimpact failure or malfunction that would have precluded normal operation When actuated both the toe brakes and the parking brake were functional Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS The failure of the pilot of another airplane to set the parking brake and to maintain a proper visual lookout which resulted in an
62. 1999 2012 Air Data Research Page 22 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database He was asked if during the flight he had any smell of fuel He said that there was no odor and he didn t notice any spray He stated that during the preflight he had not noticed any abnormalities due to fuel leakage and he had done a walk around He was also asked if the student mentioned to him any abnormalities conceming fuel leakage He stated that he was notified about any fuel issues noticed on the preflight Fueling Records Review of EKU fueling records revealed that no specific records were recorded by aircraft registration number making it impossible to determine exactly how many gallons were uploaded to a particular aircraft or to do trend analysis of fuel consumption on a per aircraft basis Security Camera Video Review of security camera video from multiple cameras revealed that at 1304 the airplane was tugged from the maintenance hangar to the fuel facility where the airplane appeared to be refueled At 1309 the airplane was then tugged to a tiedown position on the parking ramp At 1316 the instructor from the previous flight was observed to walk out to the airplane where he was joined by his student At 1320 the airplane was seen to exit th
63. 204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Section 2 1 2 DUTY PRIORITY Give first priority to separating aircraft and issuing safety alerts as required in this order Good judgment must be used in prioritizing all other provisions of this order based on the requirements of the situation at hand 2 1 6 SAFETY ALERT Issue a safety alert to an aircraft if you are aware the aircraft is in a position altitude which in your judgment places it in unsafe proximity to terrain obstructions or other aircraft Once the pilot informs you action is being taken to resolve the situation you may discontinue the issuance of further alerts Do not assume that because someone else has responsibility for the aircraft that the unsafe situation has been observed and the safety alert issued inform the appropriate controller NOTE 1 The issuance of a safety alert is a first priority see para 2 1 2 Duty Priority once the controller observes and recognizes a situation of unsafe aircraft proximity to terrain obstacles or other aircraft Conditions such as workload traffic volume the quality limitations of the radar system and the available lead time to react are factors in determining whether it is reasonable for the controller to observe and recognize such situations While a controller cannot see immediately the development of every situation where a safety alert must be issued
64. 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 92 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt ERA13FA186 04 03 2013 1600 EDT Regis N3101H Miami FL Apt Kendall Tamiami Executive Airp TMB Acft Mk MdI ROBINSON R44 Acft SN 1610 Acft Dmg DESTROYED Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING 0 540 F1B5 AcftTT 760 Fatal 2 Serlnj 0 Fit Conducted Under FAR 091 Opr Name BRAVO HELICOPTERS LLC Opr dba Aircraft Fire GRD Narrative HISTORY OF FLIGHT On April 3 2013 about 1600 eastern daylight time Robinson R44 N3101H had components separate in flight and the helicopter impacted the ground shortly after takeoff from Kendall Tamiami Executive airport TMB Miami Florida The helicopter was registered to and operated by Bravo Helicopters LLC of Miami Florida The commercial pilot and pilot rated mechanic incurred fatal injuries The maintenance test flight was conducted under the provisions of 14 Code of Federal Regulations Part 91 Visual meteorological conditions prevailed and no flight plan was filed for the local flight that departed a few minutes before the accident Multiple witnesses in the vicinity of the crash site reported hearing a loud pop noise and seeing par
65. 4FA183 05 07 2014 855 MDT Regis N8236F Santa Clara UT Acft Mk Mdl CESSNA 150 F F Acft SN 15064336 Acft Dmg SUBSTANTIAL Rpt Status Prelim Prob Caus Pending Fatal 2 Serlnj 0 Fit Conducted Under FAR 091 Opr Name ABOVE VIEW AVIATION Opr dba Aircraft Fire NONE Narrative On May 7 2014 about 0855 Mountain daylight time a Cessna 150F airplane N8236F sustained substantial damage following impact with remote mountainous terrain while maneuvering about 3 nautical miles nm west of Santa Clara Utah The airplane was owned and operated by Above View Aviation Saint George Utah The certified flight instructor who occupied the right cockpit seat and the pilot receiving instruction who occupied the left cockpit seat were fatally injured Visual meteorological conditions prevailed for the local instructional flight which was being operated in accordance with 14 Code of Federal Regulations Part 91 A flight plan was not filed The flight had departed the Saint George Municipal Airport SGU Saint George Utah about 0800 In a statement provided to the National Transportation Safety Board NTSB investigator in charge IIC by local law enforcement personnel a witness reported that he and a family member were riding the Rim Trail when they observed the airplane overhead proceeding west The witness stated that after a few minutes he heard the airplane sputter and the nose diving then lost sight of it when it went behind a hill he didn t hear a
66. 5 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt WPR12LA023 10 28 2011 1350 PDT Regis N520YH Prineville OR Apt Bend Municipal Airport BDN Acft Mk Mdl CESSNA 185 Acft SN 18503619 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl TELEDYNE CONTINENTAL 10 550 AcftTT 8134 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name TIMOTHY TURNBULL Opr dba Aircraft Fire NONE Summary During the descent to the destination airport when the airplane was about 10 miles out and descending through about 6 500 feet the engine experienced a total loss of power In response to the power loss the pilot manipulated the throttle mixture and propeller controls but the engine did not regain power When the pilot recognized that the airplane would not be able to reach the destination airport he conducted a forced landing on an unpaved road During the landing roll at a groundspeed of about 10 mph the airplane struck some vegetation and it then nosed over onto its back The pilot reported that at the time of the engine power loss the electronic fuel flow instrument indicated that 16 gallons of usable fuel was remaining which he believed was sufficient fuel for about 1 more hour of flight and to reach the destination airport During recovery the fuel tanks were observed to contain about 16 gallons of total fuel and the fuel selector handle was fou
67. 7749 reported that he was number three for departure behind N602FT While the pilot was looking at the tachometer the airplane slowly moved forward struck N602FT and severed the outer 2 feet of the left outboard portion of N602FT s horizontal stabilator The pilot realized after the collision that he had not set the parking brake He thought that his feet were on the brake pedals but that he did not put much pressure on them before the crash Postaccident examination of N47749 s brake system did not reveal evidence of any preimpact failure or malfunction that would have precluded normal operation When actuated both the toe brakes and the parking brake were functional Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS The pilot s failure to set the parking brake and to maintain a proper visual lookout which resulted in an on ground collision with another airplane Events 1 Standing engine s operating Loss of control on ground 2 Standing engine s operating Ground collision Findings Cause Factor 1 Aircraft Aircraft systems Landing gear system Landing gear brakes system Incorrect use operation C 2 Personnel issues Task performance Use of equip info Use of equip system Pilot C 3 Personnel issues Action decision Action Incorrect action performance Pilot C 4 Personnel issues Psychological Attention monitoring Task monitoring vigilance Pilot C Narrative HISTORY OF FLIGH
68. 8 EDT Regis N631DP Bloomsburg PA Apt N a Acft Mk MdI ENSTROM F 28C Acft SN 492 2 Acft Dmg MINOR Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING HIO 360 E1AD AcftTT 2198 Fatal 1 Serlnj 0 Fit Conducted Under FAR 091 Opr Name HERITAGE ROTORS LLC Opr dba Aircraft Fire NONE Narrative On September 27 2013 at 1938 easter daylight time an Estrom F 28C N631DP received minor damage when a relieved pilot who was walking from the helicopter was fatally injured after coming into contact with a rotating main rotor blade near Bloomsburg Pennsylvania The airline transport pilot seated at the controls in the helicopter was the sole occupant and was not injured The helicopter was registered to and operated by Heritage Rotors LLC under the provisions of Title 14 Code of Federal Regulations Part 91 as a local sightseeing flight at a local fair Day visual meteorological conditions prevailed and no flight plan had been filed The flight was originating at the time of the accident According to the pilot owner s written statement in the NTSB Pilot Operator Aircraft Accident Incident Report he approached the left side of the helicopter and rested on the seat and looked into the helicopter he was looking down onto the pilot seat considering the location of the pilot seat belt the headset and the general condition of the interior At this point nothing in the cockpit was touched and was exactly as the relieved pilot had left it It was
69. 999 2012 Air Data Research Page 69 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt CEN14LA245 05 19 2014 930 MDT Regis N9631C Yuma CO Apt Yuma Municipal Airport 2V6 Acft Mk Mdl PIPER PA 28 181 181 Acft SN 28 7890431 Acft Dmg SUBSTANTIAL Rpt Status Prelim Prob Caus Pending Eng Mk Mdl LYCOMING 0 360 Fatal 0 SerInj 0 Fit Conducted Under FAR 091 Opr Name HEARTLAND AVIATION INC Opr dba Aircraft Fire NONE Narrative On May 19 2014 about 0930 mountain daylight time a Piper model PA 28 180 airplane N9631C was substantially damaged when it departed the runway during takeoff at Yuma Municipal Airport 2V6 Yuma Colorado The student pilot was not injured The airplane was registered to and operated by Heartland Aviation Incorporated under the provisions of 14 Code of Federal Regulations Part 91 without a flight plan Day visual meteorological conditions prevailed for the student solo cross country flight that was destined for Alliance Municipal Airport AIA Alliance Nebraska The student pilot reported that after referencing the airport windsock he decided to takeoff using runway 16 4 200 feet by 75 feet concrete He stated that before achieving rotation speed the airplane encountered a wind gust that rais
70. A 4 5 part number 10 3676 serial number MS820601 carburetor Logbook copies included an Authorized Release Certificate FAA Form 8130 3 which stated the carburetor was overhauled by Marvel Schebler Aircraft Carburetors LLC The date of FAA Form 8130 3 was July 25 2013 Copies of logbook entry dated June 25 2013 at a tachometer time of 4 571 hours stated that an annual inspection was performed An entry dated October 21 2013 at a tachometer time of 4 626 hours stated that the carburetor was removed and replaced with an overhauled carburetor referencing Form 8130 2 The airplane owner said that the tachometer time at the time of the accident was 4 669 hours Post accident disassembly examination of the airplane under the supervision of the IIC and an FAA inspector from Dupage Flight Standard District Office revealed that the fuel screen did not contain contaminant the idle screw was extended about 2 turns and the throttle valve and float had clearances from the carburetor body that were within service manual specifications All of the carburetor retaining hardware was in place and secure Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 15 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database
71. Board Aircraft Accident Incident Database unusual attitude is detected the recommended recovery procedures should be initiated by reference to the ASI altimeter VSI and tum coordinator According to the FAA Airplane Flying Handbook FAA H 8083 3A The pilot should remember that unless instrument flying tasks are practiced ona continuing and regular basis skill erosion begins almost immediately In a very short time the pilot s assumed level of confidence will be much higher than the performance he or she will actually be able to demonstrate should the need arise A VER pilot is in IMC conditions anytime he or she is unable to maintain airplane attitude control by reference to the natural horizon regardless of the circumstances or the prevailing weather conditions This situation must be accepted by the pilot involved as a genuine emergency requiring appropriate action Service Letter Number 52A issued on March 23 2006 by the Nichols Airborne Division Parker Hannifin Corporation stated that Airborne air pumps with any model number beginning with 200 through 216 must not be operated beyond the mandatory replacement time of 500 aircraft hrs or 6 years from date of manufacture whichever comes first The service letter continued with the following caution WARNING Failure of the air pump will result in the loss of the pneumatically powered gyro flight instruments Service Letter Number 66 issued on January 21 2007
72. Cherokee utilizing the call sign Cherokee 08W and 08W and a Piper Tomahawk call sign 11T Audio data revealed a beeping sound during the controller s transmissions which was consistent with an automatically generated aural conflict alert Radar playback data also revealed that at that time the controller was also receiving a visual alert on the radar console During that period the Travis Approach Radar Assist controller Radar Associate Position received a land line interphone call from a NORCAL approach controller who had also received the alert and was concemed about the proximity of N7508Y and N433JC The assist controller responded yeah we re givin him traffic Radar data indicated that the helicopter and N433JC were now at the same altitude of 2 600 feet within 1 mile of each other and closing The Travis Approach controller then transmitted Zero eight yankee traffic now twelve o clock less than a mile east correction westbound two thousand six hundred indicated A few seconds later the radar targets merged and the pilot of N7508Y transmitted MAYDAY MAYDAY HELICOPTER GOING DOWN Examination of the radar data revealed that the helicopter s mode C reported altitude varied between 2 600 and 3 300 feet during the period it was receiving flight following No other targets were observed in close proximity to the two aircraft leading up to the collision Interpretation of the voice recordings revealed that although the helicopter pilot
73. Disorientation Surface references and the natural horizon may at times become obscured although visibility may be above visual flight rule minimums Lack of natural horizon or surface reference is common on over water flights at night and especially at night in extremely sparsely populated areas or in low visibility conditions A sloping cloud formation an obscured horizon a dark scene spread with ground lights and stars and certain geometric pattems of ground lights can provide inaccurate visual information for aligning the aircraft correctly with the actual horizon The disoriented pilot may place the aircraft in a dangerous attitude tests conducted with qualified instrument pilots indicated that it can take as long as 35 seconds to establish full control by instruments after a loss of visual reference of the earth s surface AC 60 4A further states that surface references and the natural horizon may become obscured even though visibility may be above VFR minimums and that an inability to perceive the natural horizon or surface references is common during flights at night in sparsely populated areas and in low visibility conditions According to the FAA Instrument Flying Handbook FAA H 8083 5B One possible cause of instrument failure is a loss of the suction or pressure source This pressure or suction is supplied by a vacuum pump mechanically driven off the engine Occasionally these pumps fail leaving the pilot with inoperative atti
74. Friday Harbor Washington approximately 20 minutes before the accident A flight plan had not been filed The pilot said that while on landing roll he applied left rudder to straighten the airplane with no response He said he attempted to correct the right veering tendency with left braking action and that was ineffective as well The airplane departed the right side of the runway and impacted an airport sign and a ditch which damaged the right wing Postexamination of the left rudder control bar found that it had failed Examination of the rudder control bar at the NTSB Materials Laboratory found a fatigue crack which originated from the edge of a weld There was a rusted brown oxidized area near the middle of the crack and the surface of this area had topography and crack patterns consistent with slow growth fatigue progressing from the exterior surface radially through the tube wall The airplane was manufactured in 1970 and according to the owner it had an airframe total time of 3 479 hours when the accident occurred The most recent annual inspection was completed on May 25 2013 A review of the Piper Aircraft s periodic inspection checklist maintenance manual and Service Letter No 671 dated October 5 1973 indicated that the rudder bar assembly should be inspected every 100 hours specifically for cracks in the area where the airplane s rudder bar failed Further the Service Letter stated that these periodic inspections could be discont
75. Incident Database Accident Rpt CEN14CA209 04 21 2014 730 EDT Regis N405S Put In Bay OH Apt Nia Acft Mk Mdl PIPER PA 28 181 181 Acft SN 2890015 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING 0 amp VO 360 SER AcftTT 8599 Fatal 0 Serlnj 0 Fit Conducted Under FAR 135 Opr Name GRIFFING FLYING SERVICE Opr dba Aircraft Fire NONE Summary The pilot and three passengers were on a short cross country flight As they approached their destination airport and while on final approach the airplane collided with a goose The pilot was able to land the airplane uneventfully Examination of the airplane revealed substantial damage to the outer section of the right wing Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS An inflight collision with a goose while on an approach Events 1 Approach Controlled flight into terr obj CFIT Findings Cause Factor 1 Environmental issues Physical environment Object animal substance Animal s bird s Not specified C Narrative The pilot and three passengers were on a short cross country flight As they approached their destination airport and while on final approach the airplane collided with a goose The pilot was able to land the airplane uneventfully Examination of the airplane revealed substantial damage to the outer section of the right wing Printed May 22 2014 an airsafety com e product Copyright 1
76. NCE WAS The pilot s failure to maintain directional control during landing which resulted in the airplane veering off the runway and nosing over Events 1 Landing landing roll Loss of control on ground Findings Cause Factor 1 Personnel issues Task performance Use of equip info Aircraft control Pilot C 2 Aircraft Aircraft oper perf capability Performance control parameters Directional control Not attained maintained C Narrative The pilot reported that after an approximate one hour flight he retuned back to the departure airport which is where the airplane was based He configured the airplane for a three point landing and touched down about 300 feet after the runway threshold Upon touchdown the airplane immediately began to veer to the right The airplane continued off the runway surface and nosed over coming to rest inverted During the accident sequence the vertical stabilizer and rudder were substantially damaged The pilot reported no pre impact mechanical malfunctions or failures that would have precluded normal operation Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 40 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt WPR11FA430 09 04 2011 1125
77. NG 0 540 A1A AcftTT 3550 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name MCBRIDE MARK R Opr dba Aircraft Fire NONE Narrative On December 5 2013 about 1500 Pacific standard time a Piper PA 24 airplane N6595P sustained substantial damage during an off airport forced landing within the city limits of Fair Oaks Califomia The airplane was being operated by the pilot as a visual flight rules VFR personal cross country flight under the provisions of 14 Code of Federal Regulations Part 91 The solo pilot received minor injuries Visual meteorological conditions prevailed and the pilot was participating in air traffic control ATC flight following The airplane departed the Salinas Airport KSNS Salinas Califomia about 1400 and was bound for the Auburn Municipal Airport KAUN Aubum California During a telephone conversation with the National Transportation Safety Board NTSB investigator in charge IIC on December 9 the pilot stated that he departed Salinas for his home airport in Aubum He said that he has made the flight on numerous occasions Typically he departs Salinas Airport climbs to 6 500 feet above sea level msl and requests flight following services When he gets close enough to see his destination he requests a descent to 3 500 feet msl and continues to the destination airport The pilot said the flight proceeded normally until he requested the descent to 3 500 feet msl After being granted the descent he throttl
78. National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt CEN14LA221 04 21 2014 1422 Regis N481HY Peyton CO Apt Meadow Lake FLY Acft Mk MdI AMERICAN AA 1 UNDESIGNAT Acft SN AA1 0048 Acft Dmg DESTROYED Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING 0 320 A2B AcftTT 3735 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name PILOT Opr dba Aircraft Fire GRD AW Cert STN Narrative On April 21 2014 at 1422 mountain daylight time an American AA 1 N481HY veered off runway 15 and impacted runway signs and terrain at Meadow Lake Airport FLY Colorado Springs Colorado The airplane was destroyed by a postcrash fire The airline transport pilot was uninjured The airplane was registered to and operated by the pilot under 14 CFR Part 91 as a maintenance test flight The flight was not operating on a flight plan Visual meteorological conditions prevailed for the flight that originated at FLY about 1422 and was to remain in the airport traffic pattern for the flight The pilot who was also the airplane owner stated he performed preflight and pre takeoff checks of the airplane prior to a post owner assisted annual inspection test flight He departed from runway 15 for the first takeoff and remained in left closed traffic for touch and go landings He performed the first landing to a full stop to test the airplane brakes and then taxied back to runway 15 He did not notice any anomalies with the airplane an
79. On multiple occasions the controllers for each sector misidentified the last three digits of the helicopter s call sign Additionally the controller in the accident sector issued a traffic advisory using the wrong call sign Further an aircraft with the same last three digits as the helicopter s incorrect call sign made radio contact with the controller shortly before the collision which increased the confusion lt Audio data revealed that the air traffic controller provided multiple traffic advisories to the helicopter but did not issue an alternate or immediate course of action in accordance with ATC procedures despite the fact that the aircraft s converging flightpaths had triggered the radar conflict alert system Radar playback also revealed that at that time the controller was receiving a visual alert on the radar console This alert was also observed by a controller in an adjacent approach sector who called the radar assist controller warning of the threat The assist controller responded yeah we re givin him traffic A few seconds later the radar targets merged The helicopter pilot stated that she received and complied with the traffic advisories by performing a visual scan but that based on her communications with the air traffic controller she did not perceive the situation to be urgent Radar data revealed that the helicopter descended 600 feet before the collision but that the pilot did not inform the air traffic controllers abo
80. PDT Regis N7WJ Tehachapi CA Apt N a Acft Mk Mdl CESSNA P210 N Acft SN P21000374 Acft Dmg DESTROYED Rpt Status Factual Prob Caus Pending Eng Mk Mdl CONTINENTAL MOTORS TSIO 520 Fatal 2 Serlnj 0 Fit Conducted Under FAR 091 Opr Name WALTER L JOHNSON TRUSTEE Opr dba Aircraft Fire GRD Narrative HISTORY OF FLIGHT On September 4 2011 at 1125 Pacific daylight time a Cessna P210N N7W4 collided with trees near Tehachapi California The pilot owner was operating the airplane under the provisions of 14 Code of Federal Regulations CFR Part 91 The pilot and one passenger sustained fatal injuries the airplane was destroyed from impact forces and a post crash fire The local personal flight departed Cable Airport Upland California at 1023 Visual meteorological conditions prevailed and no flight plan had been filed The pilot called a friend who had a home near Tehachapi and indicated that he would fly over the home later that morning on a pleasure flight A witness at the Mountain Valley Airport in Tehachapi possessed commercial pilot certificates for airplane single engine and multiengine land as well as an instrument rating He was working on a glider rating at Mountain Valley and was familiar with the surrounding area He noticed an airplane approaching the airport from the southeast on a northwesterly heading The airplane was low over the wind turbines in the area and after clearing the ridge line that they were on began a 360 degree t
81. RS that performed the repair in June 2011 and according to documents provided by the facility a 1 8 inch long shallow crack was noted near the actuator attach lugs The crack was blended in accordance with Cessna Service Bulletin MEB91 11 Revision 1 and a Fluorescent Dye Penetrant inspection of the area was then performed No further crack was detected so the part was painted and retumed to service on July 26 2012 A copy of the records from the repair station is contained in the NTSB public docket According to the airplane maintenance records during a routine Phase 5 inspection on August 3 2012 at airframe total time of 27 968 1 hours nose landing gear drag brace P N 5142002 5 T351 19 was installed onto the incident airplane Since installation the nose landing gear drag brace was visually inspected in situ twice during a special inspection of the rod end area for condition and security The first occurred during a Phase 6 inspection performed on August 15 2012 at airframe total time of 28 025 6 hours and the second occurred during a Phase 1 inspection performed on August 27 2012 at airframe total time of 28 074 6 hours The airplane total time at the time of the incident was reported to be 28 098 6 hours The airplane had been operated for approximately 131 hours and approximately 218 cycles based on the 2012 average utilization of 0 6 hour per cycle since the repaired nose landing gear drag brace was installed Since actual cycles is not t
82. T On May 22 2012 about 2200 eastern daylight time a Piper PA 28 161 N602FT was substantially damaged when it was struck from behind by a Piper PA 28 161 N47749 while holding short on taxiway Alpha behind another airplane at Melbourne Intemational Airport MLB Melbourne Florida Both airplanes were operated by FIT Aviation LLC The certificated flight instructor and certificated private pilot in N602FT and the certificated private pilot in N47749 were not injured Night visual meteorological conditions prevailed and no flight plans were filed for the instructional flights operated under Title 14 Code of Federal Regulations CFR Part 91 According to the flight instructor in N602FT he and his student were stopped behind a Cessna who was holding short of runway 9R on taxiway Alpha The flight instructor noticed another airplane stop behind them while they were waiting for departure A few seconds later they were struck from behind Their position lights landing light and strobe lights were illuminated when the accident occurred According to the private pilot in N47749 he was dispatched about 2120 eastem daylight time He had completed his takeoff and landing data card and then did a preflight inspection of N47749 After entering the airplane and starting the engine he then taxied to the designated run up area where he performed the Ground Check checklist Upon contacting ground control he received instructions to taxi to runway 9R via tax
83. The closest weather reporting facility was Petersburg Airport approximately 14 miles west of the accident site At 1536 an aviation routine weather report METAR at Petersburg Alaska reported wind calm visibility 2 1 2 statute miles with light rain and mist scattered clouds at 500 feet broken clouds at 1 300 feet overcast clouds at 1 800 feet temperature 52 degrees F dewpoint 48 degrees F altimeter 30 03 inHG WRECKAGE AND IMPACT INFORMATION Assisted by the United States Coast Guard and two volunteers from Juneau Mountain Rescue the NTSB IIC along with an Alaska State Trooper reached the accident site on the afternoon of June 5 The on scene examination revealed that the airplane impacted in a near vertical attitude on a tree covered 37 degree slope at an elevation of about 912 feet mean sea level The nose of the airplane was on approximately a 30 degree heading and uphill All headings bearings noted in this report are magnetic The average heights of the trees surrounding the accident site were in excess of 200 feet tall All of the airplanes major components were found at the main wreckage site An area believed to be the initial impact point was marked by a broken treetop approximately 80 feet from the main wreckage site Approximately 4 feet of the outboard section of the right wing was found at the base of the tree The airplane s right wing separated into 3 sections with the largest section remaining attached to the af
84. The personal local flight departed El Monte Airport El Monte California about 1400 with a planned destination of Torrance Visual meteorological conditions prevailed and no flight plan had been filed In a written statement the pilot reported that he landed and received a clearance to taxi to his hangar During taxi he attempted to make a left turn and found that despite inputting full left pedal the airplane would not tum The airplane veered off the taxiway surface into the dirt median and continued onto the main ramp area The pilot could not stop the airplane prior to its left wing colliding with a parked vehicle that was located on the ramp A Federal Aviation Administration FAA inspector and aviation mechanic performed a postaccident examination of the airplane The FAA inspector stated that the ruddervator system was examined from the cockpit to the ruddervators and there was no evidence of mechanical malfunctions or failures The nose wheel steering was also inspected and operationally checked while the airplane was on jacks and no abnormalities were discovered The inspector found no anomalies with the airplane that would have precluded normal operation Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com Page 8 Natio
85. a Research Page 51 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt ERA14FA231 05 09 2014 1940 EDT Regis N3016Z Ruther Glen VA Apt N a Acft Mk Mdl EAGLE C 7 Acft SN EE207203 Acft Dmg DESTROYED Rpt Status Prelim Prob Caus Pending Fatal 3 Serlnj 0 Fit Conducted Under FAR 091 Opr Name KIRK DANIEL T Opr dba Aircraft Fire IFLT AW Cert STB Narrative On May 9 2014 about 1940 eastem daylight time an Eagle C 7 Balloon N3016Z was destroyed by fire after a landing attempt to a field and subsequent impact with powerlines near Ruther Glen Virginia The commercial pilot and two passengers were fatally injured Visual meteorological conditions prevailed and no flight plan was filed for the local personal flight that departed from Meadow Event Park Doswell Virginia approximately 3 75 miles to the south of the accident location The flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91 Multiple eyewitnesses reported that the accident balloon approached a field from the south where another balloon had just landed As the accident balloon approached the landing site the pilot engaged the bumer however the balloon struck powerlines which resulted in a spark Subsequently the balloon
86. above mean sea level the engine lost power The flight instructor then performed the emergency procedures and attempted to restart the engine without result He then realized that they would be unable to make the runway so he decided to make an off airport landing He chose a field and then proceeded with an emergency landing The emergency landing was uneventful and the airplane touched down in the grass covered field in slightly uphill terrain During the landing rollout as the airplane came to the crest of the hill he saw a tree immediately in front of them He put in full control input to the left to try and miss the tree but he could not get the airplane to tum to the left fast enough and the right wing impacted the tree PERSONNEL INFORMATION Flight Instructor According to Federal Aviation Administration FAA and pilot records the flight instructor held a commercial pilot certificate with ratings for airplane single 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 July 21 2011 He reported that he had accrued 453 total hours of flight experience 351 hours of which were in the accident airplane make and model 321 hours as pilot in command and 157 hours as a flight instructor Student Pilot According to FAA and pilot records the student pilot held a student pilot certificate His most recent FAA f
87. accident examination of N47749 s brake system did not reveal evidence of any preimpact failure or malfunction that would have precluded normal operation of the brake system When actuated both the toe brakes and the parking brake were functional Brake Servicing and Maintenance Records The brake system was filled with MIL H 5606 hydraulic brake fluid The fluid level would be checked periodically and replenished when necessary If the entire system had to be refilled it would be filled with fluid under pressure from the brake end of the system No adjustment of the brake clearances was necessary If after extended service the brake blocks became excessively worn they were replaced with new segments Review of maintenance records indicated that the brake pads had been replaced on July 1 2011 and the left brake disc had been replaced on August 9 2011 Further review also did not reveal any recent failures or malfunctions that would have precluded normal operation of the brake system Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 84 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Brake Operation The brakes were actuated by toe brake pedals which were attached to the rudder pedals or by a ha
88. acking or failure of the nose landing gear drag brace 1 duplicate entry was noted Of the 13 reports 5 were submitted by the operator Between 2002 and March 12 2014 SDR run date excluding the SDR submitted for the incident event there were 3 reports involving either cracking or failure of nose landing gear drag brace P N 5142002 5 of which 2 were submitted by the operator Of the 2 reports submitted by the operator 1 related to finding the nose landing gear drag brace cracked at regular scheduled inspection and the other in May 2010 which was the only one submitted in 2010 related to collapse of the nose landing gear due to failure of the nose landing gear drag brace In 2011 and in 2012 excluding the incident event the operator or the FAA CRS who was inspecting the nose landing gear drag braces for the operator did not submit any Malfunction or Defect Report concerning cracking of the nose landing gear drag braces A copy of the SDR s is contained in the NTSB public docket According to records generated by the FAA CRS that last inspected the failed nose landing gear drag brace between 2002 and 2012 the operator submitted to them a total of 1 216 nose landing gear drag braces for MEB91 11R1 inspection Of those a total of 1 102 were repaired and 114 were cracked beyond the allowable repair limit of MEB91 11R1 Specifically in 2010 a total of 161 nose landing gear drag braces were inspected per MEB91 11R1 of which 24 were found to be cracke
89. act Travis approach At approximately 1832 the pilot made contact with Travis approach utilizing the call sign Helicopter 7508Y The controller replied with the call sign of 08W while asking her to verify altitude The pilot responded with an altitude of 3 000 feet and restated her call sign as 08Y and again the controller replied with the incorrect call sign The pilot retransmitted the correct call sign and over the next few exchanges the discrepancy was resolved and the controller responded with the correct call sign At 1838 the controller once again utilizing the incorrect call sign of 08W provided a traffic advisory to the helicopter pilot regarding a twin Cessna airplane The pilot replied stating is that for 08Y and the controller replied in the affirmative now utilizing the O8Y call sign Ninety seconds later the controller gave a second advisory stating that the Twin Cessna was at her 12 o clock position southwest bound and at 3 900 feet A few seconds after that the controller reported that the traffic was no longer a factor and the helicopter continued uneventfully Approximately 1840 a target appeared on radar approximately 11 miles southeast of N7508Y transmitting a beacon code of 1200 and an indicated mode C Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 97 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helot
90. ading edge aft crushing with two elliptical impact areas The right horizontal stabilizer was relatively undamaged The left elevator separated at the outboard attach point but remained attached at the inboard attach point The right elevator remained attached to its respective attach points The cowling was crushed upwards and aft The engine assembly separated from the engine firewall and had impact damage to the front and underside The exhaust tube had malleable bending and folding producing sharp creases that were not cracked or broken along the creases The propeller and hub remained attached to the engine crankshaft Two of the three propeller blades exhibited extensive bending and torsional S twisting The third propeller blade exhibited extensive leading edge gouges substantial torsional S twisting and chordwise scratching Due to impact damage control continuity could not be established at the accident site The on scene examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 50 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rp
91. aft Fire NONE Summary According to a written statement provided by the pilot to a Federal Aviation Administration inspector he performed a three point landing in the tailwheel equipped airplane The airplane bounced two times and then it veered to the right According to a written statement from the passenger the approach was normal but the problems started after touchdown The airplane tumed to the right the pilot initiated a go around however the left wing rose up and the airplane lost control to the right The airplane came to rest in the grass on the right side of the runway and incurred substantial damage to the firewall and fuselage A postaccident examination of the airplane revealed no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS The pilot s loss of directional control of the airplane during landing which resulted in a runway excursion Events 1 Landing landing roll Loss of control on ground 2 Landing landing roll Runway excursion 3 Landing landing roll Collision with terr obj non CFIT Findings Cause Factor 1 Aircraft Aircraft oper perf capability Performance control parameters Directional control Not attained maintained C 2 Personnel issues Task performance Use of equip info Aircraft control Pilot C Narrative According to a writt
92. after departing from Meadows Field Airport Bakersfield California The airplane was substantially damaged by the fire The pilot was operating the airplane under the provisions of 14 Code of Federal Regulations CFR Part 91 The certified flight instructor and two passengers were not injured The local personal flight was departing at the time of the accident with a planned destination of Redlands Municipal Airport Redlands Califomia Visual meteorological conditions prevailed and no flight plan had been filed The pilot reported that following departure he banked the airplane to adjoin the right crosswind of the traffic pattern for runway 30R The pilot observed smoke entering the cockpit and the engine began to only produce partial power The pilot elected to return back to the airport and configured the airplane for landing on runway 30R With the degradation of power he was unable to make it to the runway and landed in a field outside the airport s perimeter The pilot further stated that the fire was a result of a clamp failure on the turbocharger which is where the origin of the fire appeared to be The firewall was damaged by fire AIRCRAFT INFORMATION The Cessna T210N serial number s n 21063067 was manufactured in 1978 The airplane was equipped with a Teledyne Continental Motors TSIO 520R9B engine A review of the maintenance logbooks revealed that the last annual inspection was dated as having being completed on May 1 2012 at a tacho
93. ail section raised and the nose lowered which allowed the main rotor blades to strike the ground The helicopter rolled over on its left side and sustained substantial damage to the main rotor blades and fuselage The Federal Aviation Administration inspector responded to the scene an examination of the helicopter was conducted and did not reveal any evidence of mechanical malfunctions or failures that would have precluded normal operation The pilot noted that if he had kept the helicopter s nose pointed into the wind then the accident might not have occurred Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 101 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt ERA14CA220 05 04 2014 0 Regis N777LR Monroe GA Acft Mk MdI SCHLEICHER ASW 20 Acft Dmg Rpt Status Prelim Prob Caus Pending Fatal 0 Serlnj 0 Opr Name Opr dba Aircraft Fire Printed May 22 2014 an airsafety com e product 7 7 Copyright 1999 2072 Air Data Research Page 102 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Acciden
94. airplane was fueled with 24 26 gallons of fuel Shortly after takeoff the engine sputtered and experienced a total loss of power when the airplane was between 100 200 feet above ground level The pilot attempted to land on the remaining runway but landed in the overrun area The airplane bounced before landing hard The airplane was retained for further examination Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 25 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt CEN14CA191 04 08 2014 1350 Regis N5306U Albuquerque NM Apt Double Eagle li AEG Acft Mk Mdl CESSNA 172S Acft SN 17289264 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING I0 360 L2A AcftTT 6718 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name THOMAS DENTON Opr dba Aircraft Fire NONE AW Cert STN Summary The student pilot reported that he was on a solo flight practicing full stop landings The airplane bounced on touchdown resulting in one tip of the propeller striking the runway The examination of the airplane revealed that there was substantial damage to the firewall The student pilot reported that there was no malfunction or system failure of the airplane before the acci
95. airsafety com e product Copyright 1999 2012 Air Data Research Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com Page 2 National Transportation Safety Board Aircraft Accident Incident Database the intention of performing three night landings and 30 minutes of flight over Antioch and the Sacramento Delta area After departure they climbed to 2 500 feet mean sea level msl on a west heading The pilot pointed out the local power station below to the passenger and then discussed aircraft lights that he could see above and far into the distance a few seconds later they felt a collision Neither occupant observed another aircraft in close proximity prior to the collision and the pilot was concemed that they may have struck a tower or bird The airplane immediately began to shudder and roll to the right The pilot looked to the right wing and could see a hole and a piece of tubing protruding from the leading edge He established airplane control and began a 180 degree climbing left tum to 3 000 feet He confirmed that his landing lights were on throughout the flight Although his transponder was switched on and set to 1200 he had not established radio contact with any air traffic control facility prior to the collision The pilot elected to return to Byron Airport While en route he established radio contact with N
96. al the main rotor could droop to a minimum height of 72 inches According to the FAA records the helicopter was manufactured in 1980 and registered to the operator in 2010 According to the pilot owner the most recent annual inspection was performed on July 2 2013 At the time of the accident the helicopter had accumulated 2198 hours of total flight time According to the helicopter manufacturer training guide the helicopter was equipped with a crew compartment that consisted of pilot and passenger co pilot seating instrument panel radio console and pilot and co pilot flight controls mounted to the aluminum floor structure and enclosed in the fiberglass cabin shell The co pilot controls are removable and a seat cushion for the third passenger is inserted into the space vacated when the co pilot collective is removed The pilot owner reported that there were no mechanical anomalies or malfunctions with the helicopter that would have precluded normal operation prior to the accident He further reported that he and the relieved pilot both conducted every aspect of the operation purposely for our safety and that of our patrons and neighbors In addition he stated that when exiting the helicopter it is the company s practice to disengage the rotor drive system and secure the collective control by means of the friction lock In this condition the rotor blades droop below the normal height This drooping is non symmetrical and most pronounced in
97. al on the part of the controller but rather is required when the work situation permits Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com Page 4 National Transportation Safety Board Aircraft Accident Incident Database Section 2 1 2 DUTY PRIORITY Give first priority to separating aircraft and issuing safety alerts as required in this order Good judgment must be used in prioritizing all other provisions of this order based on the requirements of the situation at hand 2 1 6 SAFETY ALERT Issue a safety alert to an aircraft if you are aware the aircraft is in a position altitude which in your judgment places it in unsafe proximity to terrain obstructions or other aircraft Once the pilot informs you action is being taken to resolve the situation you may discontinue the issuance of further alerts Do not assume that because someone else has responsibility for the aircraft that the unsafe situation has been observed and the safety alert issued inform the appropriate controller NOTE 1 The issuance of a safety alert is a first priority see para 2 1 2 Duty Priority once the controller observes and recognizes a situation of unsafe aircraft proximity to terrain obstacles or other aircraft Conditions such as wor
98. al standard time a Cessna 172K N4VN experienced a total loss of engine power when the pilot applied carburetor heat during a visual approach to Quad City Intemational Airport MLI Moline Illinois The pilot performed a forced landing to a field near Milan Illinois The airplane sustained substantial damage to the right wing The commercial pilot and passenger were uninjured Visual meteorological conditions prevailed at the time of the accident The 14 CFR Part 91 personal flight was not operating on a flight plan The flight originated from Davenport Municipal Airport Davenport lowa at 1615 and was destined to MLI The pilot stated that he applied carburetor heat after the MLI air traffic control tower issued a landing clearance for runway 31 after receiving a special visual flight rules clearance to the airport When he applied carburetor heat about one mile from the runway the engine quit He performed a forced landing to a field and touched down at 10 15 mph The Federal Aviation Administration FAA Dupage Flight Standard District Office West Chicago Illinois did not send an FAA maintenance inspector to examine the airplane on scene following the accident The National Transportation Safety Board Investigator In Charge IIC then requested that the airplane owner provide the carburetor and maintenance logbook copies for examination which were provided by the owner The airplane owner stated the mechanic who had performed that last annual ins
99. ared on radar approximately 11 miles southeast of N7508Y transmitting a beacon code of 1200 and an indicated mode C Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com Page 3 National Transportation Safety Board Aircraft Accident Incident Database altitude of 1 200 feet This aircraft was not in communication with air traffic control and was later determined to be N433JC About 1842 the controller asked N7508Y how much further east she would be flying and the pilot responded We ll be over Antioch Bridge but be turning bound soon zero eight yankee The radar controller responded roger traffic one o clock 6 miles northbound altitude indicates two thousand six hundred appears level and the pilot replied zero eight yankee Fifty seconds later the controller advised the pilot that the target was now tuming northwest bound at a range of 4 miles and the pilot replied that she was turning northbound Immediately following this response an airplane with the call sign Cherokee 9808W called the approach controller requesting visual flight rules VFR flight following The controller confirmed contact and asked the Cherokee to standby Over the course of the next 73 seconds the controller corresponded multiple times with the
100. as aware that it included significant areas of water She therefore selected a road as her emergency landing spot During the approach she could see multiple automobiles and diverted to a spot adjacent to the highway She raised the collective control between 50 and 75 feet above ground level the helicopter landed hard and rolled onto its left side TESTS AND RESEARCH Radar and Audio Radar data and audio recordings for the accident were provided by the Federal Aviation Administration FAA and United States Air Force USAF and reviewed by an Air Traffic Control Specialist in the NTSB Operational Factors division A complete report is included in the public docket The data revealed that the pilot of helicopter N7508Y initially attempted to make contact with NORCAL approach about 1821 The controller did not reply and about 3 minutes later she made a second attempt The controller replied utilizing the incorrect call sign of Helicopter 7508W and the pilot utilizing the O8Y call sign requested flight following to Sacramento Executive Airport via Concord and Antioch The controller again responded with 08W and provided an altimeter setting The pilot restated her call sign and the controller responded now utilizing 08Y expounding that her transmissions were fairly scratchy and hard to read She was provided with a transponder code and the flight continued uneventfully for the next 6 minutes after which time the controller asked her to cont
101. ascolator was compromised due to impact as was the fuel inlet fitting to the carburetor The gascolator bowl and screen were clear of debris No fuel was observed The lower swash plate interrupter was attached to the swash plate The slider tube was sheared from the mount and was ripped around to the top The swash plate rotated roughly by hand The swash plate assembly for the blue blade exhibited a pitch link that was bent in the center section and at the lower rod end The upper rod end fractured in a bending overload at the threaded area and remained safety wired The swash plate assembly for the red blade exhibited a disconnected lower rod end from the swash plate and the upper rod end remained attached to the pitch horn which was fractured and the attached bolt was bent The attaching hardware for the lower rod end was not recovered There was no visible deformation damage to the pitch link mounting hole A detailed report of the airframe systems and power plant examination is contained in the NTSB public docket MEDICAL AND PATHOLOGICAL INFORMATION Postmortem examinations were performed on the pilot and pilot rated mechanic by the Miami Dade Medical Examiner s office The cause of death for each was reported as blunt force injuries The FAA s Civil Aerospace Medical Institute performed forensic toxicology on specimens from the pilot and pilot rated mechanic The tests were negative for carbon monoxide cyanide drugs and ethanol TESTS
102. atabase the intention of performing three night landings and 30 minutes of flight over Antioch and the Sacramento Delta area After departure they climbed to 2 500 feet mean sea level msl on a west heading The pilot pointed out the local power station below to the passenger and then discussed aircraft lights that he could see above and far into the distance a few seconds later they felt a collision Neither occupant observed another aircraft in close proximity prior to the collision and the pilot was concemed that they may have struck a tower or bird The airplane immediately began to shudder and roll to the right The pilot looked to the right wing and could see a hole and a piece of tubing protruding from the leading edge He established airplane control and began a 180 degree climbing left tum to 3 000 feet He confirmed that his landing lights were on throughout the flight Although his transponder was switched on and set to 1200 he had not established radio contact with any air traffic control facility prior to the collision The pilot elected to return to Byron Airport While en route he established radio contact with Northern Califomia Terminal Radar Approach Control NORCAL who told him he had struck a helicopter He maintained straight and level flight by utilizing continuous left aileron and rudder control inputs During the final approach segment the propeller speed began to decrease and he was unable to maintain altitude As the air
103. ation provided by the operator the first historical documentation associated with nose landing gear drag brace P N 5142002 5 was Federal Aviation Administration FAA Form 8130 3 associated with a repair by a FAA Certificated Repair Station FAA CRS dated June 19 2011 Review of the FAA Form 8130 3 Form associated with the June 19 2011 repair revealed the part was cleaned repaired inspected and was approved for return to service by the FAA CRS The form also indicates that the nose landing gear drag brace was Inspected and Repaired in accordance with MEB 91 11 Rev 1 as supplied by customer Replaced four bearings Identified crack repaired I A W Above MEB Unit ID spotted to alert compliance with MEB Painted and retumed unit to service At this repair the part was identified with serial number S N T35119 A copy of the FAA Form 8130 is contained in the NTSB public docket Following the repair the nose landing drag brace was installed in another airplane N68391 on June 29 2011 and removed from that airplane on November 11 2011 after accruing 473 4 hours On December 22 2011 the drag brace was installed onto N26514 and was removed from that airplane on July 24 2012 after accruing approximately 530 hours since installation or a total of 1 003 hours since being reworked in June 2011 A copy of the installation and removal records is contained in the NTSB public docket The nose landing gear drag brace was then sent to the same FAA C
104. ational issues Management Policy procedure Adequacy of policy proc Operator F 5 Aircraft Fluids misc hardware Fluids Fuel Inadequate inspection F 6 Personnel issues Task performance Inspection Preflight inspection Student instructed pilot F 7 Personnel issues Task performance Inspection Preflight inspection Instructor check pilot F 8 Personnel issues Task performance Planning preparation Fuel planning Instructor check pilot F Narrative HISTORY OF FLIGHT On April 19 2012 at 1600 eastern daylight time a Cessna 172R N28BC operated by Eastern Kentucky University EKU was substantially damaged after Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 18 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database impacting a tree during landing roll after a forced landing in Richmond Kentucky The certificated flight instructor and student pilot were not injured Visual meteorological conditions prevailed and no flight plan had been filed for the instructional flight which was conducted under the provisions of Title 14 Code of Federal Regulations CFR Part 91 between Hisle Field Airport 75KY Winchester Kentucky and Madison Airport 139 Richmond Kentucky According to the flight in
105. ator his total aeronautical experience was about 4 841 flight hours of which about 1 465 were in same make and model as the accident airplane In the preceding 90 and 30 days prior to the accident the pilot flew a total of 114 1 and 45 7 flight hours His most recent CFR Part 135 293 check ride was on February 5 2013 A Federal Aviation Administration FAA operations inspector from the Juneau Flight Standards District Office FSDO administered the check ride in an amphibious float equipped Cessna 185 airplane AIRCRAFT INFORMATION The airplane was a 1958 model year de Havilland DHC 2 MK1 Beaver At the time of the accident the airplane had a total time in service of 34 909 3 flight hours A review of the maintenance records revealed that the most recent annual inspection of the airframe and engine was on January 22 2013 76 1 flight hours before the accident The airplane was equipped with a Pratt and Whitney R 985 radial engine that was rated at 450 horsepower The engine was overhauled 1 015 6 hours before the accident The airplane was equipped with Edo 4930 floats According to the performance information section of the airplane s FAA approved flight manual the stall speed for a DHC 2 airplane configured with the flaps in the up position operating at 5 057 pounds the estimated gross weight of the airplane at the time of the accident ranges between 60 and 105 miles per hour depending on bank angle METEOROLOGICAL INFORMATION
106. basket and a section of the envelope caught fire The balloon began an accelerated climb and drifted out of sight The debris path was approximately 1 75 miles in length and was oriented on a 025 degree heading from the attempted landing field Two stainless steel propane fuel tanks a hand held fire extinguisher the instrument panel and various pieces of the charred envelope fabric associated with the lower portion of the balloon envelope were recovered along the debris path Both propane fuel tanks were intact but exhibited thermal and impact damage The balloon crown crown ring deflation port the bumer and two other propane fuel tanks were not recovered The balloon was equipped with four propane tanks a wicker basket and a 78 133 cubic foot envelope The most recent annual inspection on the balloon was performed on August 5 2013 and at that time it had accumulated 270 4 hours of total time A Garmin 12 handheld global positioning system and three cellular phones were located removed and sent to the NTSB Recorder Laboratory for download Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 52 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt ERA13LA433 09 27 2013 193
107. blade propeller with a total time since new of 1 643 7 hours and a time since overhaul of 0 hours On scene examination of the airplane by a Federal Aviation Administration FAA inspector revealed that the flaps were retracted the fuel selector was in the off position the cockpit mixture and throttle controls were at their forward stop the cockpit propeller control was at the aft stop and the fuel boost pump switch was in the off position Propeller control continuity was confirmed prior to removal of the propeller and propeller governor The propeller and propeller governor were removed by the operator s maintenance personnel and sent to McCauley Propeller Systems Wichita Kansas On July 19 2013 the propeller and governor were tested and examined under the supervision of a National Transportation Safety Board NTSB Air Safety Investigator The number 1 propeller blade was part number I 80VSA 1 and serial number ZJ26152 the number 2 blade was part number I 80VSA 1 and serial number ZL26036 the number 3 blade was part number 80VSA 1 and serial number ZL26038 The propeller hub was part number B3D36C431 C and serial number 051726 All three propeller blades were able to be rotated by hand pressure while within the hub The blades did not exhibit bending twisting The number 1 blade had two leading edge dings gouges located near the outboard 1 4 span The number 2 blade had a ding tear near the tip The number 3 blade had a dent gouge located near 1
108. ble was continuous to the forward cockpit where it had been impact separated The control wheel chain was broken and fragmented The flap control cables were secure to the bellcrank but the bellcrank was impact broken and the cables were pulled inboard The landing gear was observed in the retracted position The separated outboard section of the right wing including the aileron balance weight and bellcrank assembly was found about one mile southeast from the main crash site Examination of the separation surfaces showed a positive or upward direction overload separation with no evidence of preimpact corrosion or fatigue The right aileron was partially attached and the center mounted balance weight was in place The control rod was separated The aileron bellcrank was in place and both control cable attach points were broken off The cable ends with the bellcrank parts were found with the inboard section of the wing Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 74 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database The inboard section of the right wing was found with the main wreckage The wing displayed impact compression damage from the leading edge aft to the flap area The flap displayed
109. but was decreasing The pilot descended the airplane to 7 500 feet msl at which point the airspeed stabilized at 85 KIAS and the manifold pressure was 20 9 inches Hg After a few miles the propeller speed became erratic ranging from 2 150 rpm to 2 040 rpm The pilot tried to adjust the propeller speed again by cycling the propeller and returning the propeller control knob to the full in position but the propeller speed remained erratic above and below 2 100 rpm The pilot said that shortly after diverting the flight to Blake Field Airport Delta Colorado he heard a clunking sound from the front of the airplane He said that is was not a ringing or rapping sound but a heavy muffled clunking sound The airplane lost all thrust and he performed a forced landing with no flaps extended in attempt to attain a landing to a highway The pilot turned to airplane to fly between power lines but the airplane struck the power lines while in the tum The airplane touched down on the highway and went off the right shoulder after the right main landing gear had separated The last inspection of the airplane was an annual inspection with an airplane logbook entry date of March 8 2013 at a total airframe tachometer times of 1 627 0 hours The entry stated that the propeller governor was overhauled The next entry was dated April 17 2013 and stated that an overhauled propeller was installed The propeller was a McCauley 83D36C431 C 80VSA 1 serial number 051726 three
110. ce to accomplish a business trip He attempted to instruct the student on not getting over his head with respect to flight conditions As the annual inspection on the accident airplane approached expiration the CFI told the student that the timeline for the flight practical should not be controlled by the expiration of the annual inspection Following the accident the CFI learned that the pilot was under additional personal and business stressors During preparation for the private pilot practical the student recorded 0 6 hours of simulated instrument flight time with a vision restricting device The CFI stated he never flew with the accident pilot in actual instrument meteorological conditions Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 28 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt WPR12LA365 08 20 2012 1115 Regis N735KV Mccall ID Apt N a Acft Mk Mdl CESSNA 182Q Acft SN 18265493 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl CONT MOTOR 0 470 SERIES AcftTT 3175 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name KRAUCH WILLIAM KARL TRUSTEE Opr dba Aircraft Fire NONE Summary The flight instructor reported that as he and the p
111. central daylight time a Mooney M20TN N563JK sustained substantial damage during a forced landing after a reported loss of engine power while landing at the Stinson Municipal Airport SSF San Antonio Texas The private pilot received serious injuries The airplane was registered to the Chaparral Equipment Leasing LLC and operated by the pilot under the provisions of the 14 Code of Federal Regulations Part 91 as a personal flight Visual meteorological conditions prevailed at the time of the accident and a visual flight rules flight plan was filed The flight departed SSF about 1250 on a local flight At 1253 the surface weather observation at SSF was wind variable at 3 knots sky clear temperature 30 degrees Celsius C altimeter 29 84 inches of mercury Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 63 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt ERA14CA140 03 01 2014 1750 UTC Regis N929SC Mayaguez PR Apt Eugenio Maria De Hostos TJMZ Acft Mk Mdl PIPER PA 18 150 Acft SN 18 7909002 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING 0 360 C1G Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name YELLOW MEDIA GROUP INC Opr dba Aircr
112. ched The technician briefly test ran the magneto and found it to function normally At 1956 the weather reporting facility at the Logan Cache Airport LGU Logan Utah which is located about 11 nm east of the accident site reported wind variable at 3 knots visibility 10 miles sky clear temperature 36 Celsius C dew point 7a C and an altimeter setting of 30 20 inches of mercury The density altitude at the time of the accident was calculated to be 8 830 feet Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 100 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt CEN14CA223 04 25 2014 1315CDT Regis N32VB Liberty MO Apt Roosterville ONO Acft Mk Mdl ROBINSON HELICOPTER COMPANY R44 Acft SN 10636 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING I0 540 AcftTT 1217 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name EID CO Opr dba Aircraft Fire NONE Narrative Upon arrival at the destination airport the pilot hovered the helicopter about 2 feet above the ground and prepared to land The pilot noted that during the hover while the nose of the helicopter was pointed east the wind shifted direction and gusted from the west The helicopter s t
113. cident Incident Database 140 degrees at 15 knots gusting to 20 knots 10 miles or greater visibility clear sky temperature at 23 degrees C dew point 09 degrees C and an altimeter setting at 30 10 inches of mercury WRECKAGE AND IMPACT INFORMATION The National Transportation Safety Board investigator in charge IIC an FAA inspector and investigators from Cessna and CMI examined the wreckage at the accident site The coordinates of the main wreckage were 35 degrees 04 08 minutes north latitude and 118 degrees 26 007 minutes west longitude The debris path was along a magnetic heading of 215 degrees The airplane came to rest upright on a northerly heading the engine was inverted and pointing about 90 degrees clockwise from the main wreckage The first identified point of contact FIPC was broken limbs near the top of a 20 foot tree At the base of the tree were broken limbs and the red and white left wing tip fairing containing a red navigation lens About 10 feet further into the debris path was a second tree with upper branches broken near the base of this tree was the outboard rib and about 2 feet of skin from the left wing Another 10 feet into the debris path was another tree with topped branches The debris path was about 200 feet long from the FIPC to the main wreckage and some separated pieces were about 120 feet from the debris path centerline The next point of contact was the principle impact crater PIC which began about 20 feet bef
114. com e product Copyright 1999 2012 Air Data Research Page 95 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt WPR12LA109A 02 19 2012 1845 PST Regis N7508Y Antioch CA Apt Byron C83 Acft Mk MdI ROBINSON HELICOPTER R22 BETA Acft SN 3757 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING 0 360 SERIES AcftTT 3787 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name TRACY ZEDECK Opr dba Aircraft Fire NONE AW Cert STN Summary The helicopter and airplane collided midair Both aircraft sustained minimal damage during the impact but substantial damage during the subsequent forced landings The airplane pilot was performing a local flight and was not in contact with air traffic control ATC before the collision The helicopter pilot was receiving visual flight rules flight following services from ATC throughout the flight The helicopter pilot transitioned between two ATC sectors before the accident On multiple occasions the controllers for each sector misidentified the last three digits of the helicopter s call sign Additionally the controller in the accident sector issued a traffic advisory using the wrong call sign Further an aircraft with the same last three digits as the helicopter s in
115. copic instruments were removed for laboratory examination The on scene examination of the remaining components from the airframe engine and propeller revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot by the Tarrant County Medical Examiner in Fort Worth Texas The cause of death was listed as Massive blunt force trauma of body due to light aircraft crash PILOT Forensic toxicology was performed on specimens from the pilot by the Federal Aviation Administration FAA Aeronautical Sciences Research Laboratory Oklahoma City Oklahoma The toxicology report stated NO DRUGS detected in Liver FAA records showed the pilot s most recent Third Class Limited Medical Certificate was issued on May 10 2010 with a restriction must wear corrective lenses possess glasses for near intermediate vision At that time the pilot reported that he was taking no medications TESTS AND RESEARCH Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 75 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Handheld GPS Device A fragmented and impact damaged Garmin Aero handheld GPS d
116. copy of the NTSB laboratory report is in the public docket for this case Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 36 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Incident Rpt ERA12IA550 08 31 2012 1630 EDT Regis N769EA Nantucket MA Apt Nantucket Memorial Airport ACK Acft Mk MdI CESSNA 402C Acft SN 40200303 Acft Dmg MINOR Rpt Status Factual Prob Caus Pending Eng Mk Mdl CONTINENTAL MOTORS INC AcftTT 28075 Fatal 0 Serlnj 0 Fit Conducted Under FAR 135 Opr Name HYANNIS AIR SERVICE INC Opr dba CAPE AIR Aircraft Fire NONE Summary While on approach for a full stop landing the pilot extended the landing gear and performed the Before Landing checklist The airplane landed on its main landing gear and then as the pilot lowered the nose it continued to lower until it contacted the runway Postincident examination of the airplane revealed that the nose landing gear drag bracefailed near the nose landing gear actuator attachment lug due to a fatigue crack A review of maintenance records revealed that a crack in the nose landing gear drag brace was repaired in June 2011 and that following the repair the drag brace had been installed on two other company airplanes In July 2
117. correct call sign made radio contact with the controller shortly before the collision which increased the confusion lt Audio data revealed that the air traffic controller provided multiple traffic advisories to the helicopter but did not issue an alternate or immediate course of action in accordance with ATC procedures despite the fact that the aircraft s converging flightpaths had triggered the radar conflict alert system Radar playback also revealed that at that time the controller was receiving a visual alert on the radar console This alert was also observed by a controller in an adjacent approach sector who called the radar assist controller warning of the threat The assist controller responded yeah we re givin him traffic A few seconds later the radar targets merged The helicopter pilot stated that she received and complied with the traffic advisories by performing a visual scan but that based on her communications with the air traffic controller she did not perceive the situation to be urgent Radar data revealed that the helicopter descended 600 feet before the collision but that the pilot did not inform the air traffic controllers about the descent Further as the airplane got closer and the traffic advisories were issued the helicopter pilot began tuming north which brought the helicopter directly into the path of the approaching airplane while simultaneously placing the airplane behind her immediate field of vision Shortly a
118. d beyond the allowable repair limit of the bulletin In 2011 and 2012 a total of 687 nose landing gear drag braces were inspected per MEB91 11R1 of which 51 were found to be cracked beyond the allowable repair limit of the bulletin A copy of the drag brace inspection list is contained in the NTSB public docket A review of 14 CFR Part 135 415 titled Service Difficulty Reports revealed that each certificate holder is required to report the occurrence or detection of each failure malfunction or defect in an aircraft concerning in part an unwanted landing gear retraction Additionally each certificate holder shall report any other failure malfunction or defect in an aircraft that occurs or is detected at any time if in its opinion the failure malfunction or defect has endangered or may endanger the safe operation of the aircraft A review of 14 CFR Part 145 221 titled Service Difficulty Reports pertaining to FAA Certificated Repair Stations revealed that a repair station must report to FAA within 96 hours after it discovers any serious failure malfunction or defect of an article The regulation also indicates that a certificated repair station may submit a service difficult report for a 14 CFR Part 135 certificate holder provided the report meets the requirements of Part 135 However the certificated repair station and Part 135 certificate holder must not report the same failure malfunction or defect If the certificated repair station submit
119. d by CMI under the supervision of a NTSB investigator During the examination debris was found blocking the vapor retum jet in the fuel pump Once the debris was removed the fuel pump flowed correctly A review of the left engine logbook revealed that the fuel line from the firewall to engine driven fuel pump was replaced the day prior to the accident Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com Page 7 National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt WPR12LA443 09 28 2012 1430 PDT Regis N6278V Torrance CA Apt Zamperini Field TOA Acft Mk MdI BEECH V35A Acft SN D 8602 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl CONT MOTOR 10 520 B2A AcftTT 2823 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name GERALD R STEPHENS Opr dba Aircraft Fire NONE Narrative On September 28 2012 about 1430 Pacific daylight time a Beechcraft BE V35A N6278V taxied into a parked vehicle at Zamperini Field Torrance California The pilot who owned the airplane was operating the airplane under the provisions of 14 Code of Federal Regulations Part 91 The certified flight instructor the sole occupant was not injured the airplane sustained substantial damage
120. d tried to stay off the brakes during the taxi He rechecked the magnetos and completed takeoff checks prior to a second takeoff on runway 15 During the second takeoff the airplane accelerated on the main landing gear with the tail wheel off the ground The airplane aggressively veered left and he applied full right rudder The airplane struck a runway taxiway sign before he was able to reduce the engine throttle The airplane bounced and impacted terrain between runway 15 and a parallel taxiway while striking additional airport signs The airplane came to a stop in a drainage ditch between the runway and taxiway and immediately caught fire The airplane exploded about one minute after he evacuated the airplane The pilot said that he did not know what caused the post accident fire but that the fuel tanks were ruptured during the collision with the airport signs terrain The pilot stated that the brake calipers were not removed during the owner assisted annual inspection and when asked by the National Transportation Safety Board Investigator In Charge what maintenance work was performed he said that he replaced the landing gear wheel bearings tire tubes and tires He then said that the calipers were removed when asked if the calipers had to be removed to perform the maintenance items related to the wheel bearings tire tubes and tires The brake fluid was last changed when he purchased the airplane about January 2011 He said that the annual inspection
121. d up to 48 gallons He and his instructor then taxied out and did 8 takeoffs and landings During their flight they noted no abnormalities with the airplane Student Pilot Interviews According to the student pilot who was on the accident flight the flight instructor was physically present and watched him perform the preflight on the airplane and watched him dip the fuel tanks with the fuel stick to visually check the fuel level He stated that each tank had about 20 gallons The fuel gauges also showed about the same After departing 139 they flew to 75KY to practice soft field landings After performing two landings at 75KY on the third landing he noticed the fuel gauges were down to about 5 gallons each tank Additionally he commented to his instructor concerning the condition of the field specifically that it was pretty rough At that point the decision was made to return to 139 They looked out the windows but could not see any indication of fuel leaking from the airplane He stated that about 5 miles out the engine began to run rough and lose power The instructor then took control and executed the forced landing After the forced landing the student pilot stated that he exited the aircraft and got up on each wing He stated that he could not see any fuel in either tank and that there was no indication of fuel on the dipstick He stated that he thought that he had left one and possibly both fuel caps off while checking the fuel When asked if
122. dent Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS The student pilot s improper flare that resulted in a bounced landing Events 1 Landing flare touchdown Hard landing Findings Cause Factor 1 Personnel issues Action decision Action Incorrect action performance Student instructed pilot C 2 Aircraft Aircraft oper perf capability Performance control parameters Landing flare Not attained maintained C Narrative The student pilot reported that he was on a solo flight practicing full stop landings The airplane bounced on touchdown resulting in one tip of the propeller striking the runway The examination of the airplane revealed that there was substantial damage to the firewall The student pilot reported that there was no malfunction or system failure of the airplane before the accident Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 26 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt CEN14FA071 11 29 2013 750 MST Regis N3087Y Delta CO Apt Blake Field KAJZ Acft Mk Mdl CESSNA 182E Acft SN 18254087 Acft Dmg DESTROYED Rpt Status Factual Prob Caus Pending Eng Mk Mdl CONT MOTOR O 470 SERIES AcftTT
123. dge of the horizontal stabilizer The tail rotor blades remained attached to the tail rotor gear box with one blade partially severed 9 inches outboard from the attachment point The tail rotor rotated freely There was fragmentation of bays five six and seven at the left side where the danger sticker was adhered This was consistent with a leading edge strike from a main rotor blade The tail rotor driveshaft was cut 8 inches aft of the flex coupling The tail rotor gearbox rotated freely with no abnormal noise Tail rotor flight control continuity was examined from the pedals to the tail rotor Several separations were noted due to overload and fire damage with no connections compromised Main rotor flight control continuity was examined from the cyclic and collective to the main rotor blades Several separations were noted due to overload and fire damage with no connections compromised with the exception of the pitch link to swash plate connection for blade number 3043 The pitch link horn departed the helicopter and was found 260 degrees M and 90 feet from the initial impact point The instrument panel showed crushing damage and was ripped out of the helicopter during rescue operations All canopy screens were destroyed and fragments were found at the beginning of the debris path on the roof of four buildings and at the initial impact point The carburetor mixture knob was full rich and the carburetor heat was unlocked and on All crew and passenger
124. ding The pilot circled a road but was not comfortable with landing on it and decided to land in a dry river bottom next to the road The Ventura County Sheriff responded to the accident site The pilot told the responding deputy that he became lost and disoriented over Lockwood Valley using maps and a global positioning satellite system GPS to navigate The pilot stated that the engine began to fail and he attempted to make an emergency landing when the engine finally quit The pilot attempted to land on Lockwood Valley road but was unable to do so and he landed in the river bed Investigators examined the wreckage at Aircraft Recovery Service Littlerock California on July 11 2011 Detailed examination notes are part of the public docket Postaccident examination of the engine and airframe revealed no evidence of preimpact mechanical malfunction for failure that would have precluded normal operation Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 71 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt CEN12FA164 02 20 2012 1936 CST Regis N7147P Albany TX Apt N a Acft Mk Mdl PIPER PA 24 250 Acft SN 24 2312 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending En
125. ditional Information FAA Order JO7110 65U prescribes air traffic control procedures and phraseology for use by persons providing air traffic control services According to the order Controllers are required to be familiar with the provisions of this order that pertain to their operational responsibilities and to exercise their best judgment if they encounter situations that are not covered by it The order contains the following applicable excerpts Section 2 1 1 ATC SERVICE The primary purpose of the ATC system is to prevent a collision between aircraft operating in the system and to organize and expedite the flow of traffic and to provide support for National Security and Homeland Defense In addition to its primary function the ATC system has the capability to provide with certain limitations additional services The ability to provide additional services is limited by many factors such as the volume of traffic frequency congestion quality of radar controller workload higher priority duties and the pure physical inability to scan and detect those situations that fall in this category It is recognized that these services cannot be provided in cases in which the provision of services is precluded by the above factors Consistent with the aforementioned conditions controllers must provide additional service procedures to the extent permitted by higher priority duties and other circumstances The provision of additional services is not option
126. draft on final prior to impact with the ground Multiple witnesses located adjacent to the accident site reported observing the accident airplane on final for runway 15 and suddenly descend rapidly into terrain in a normal approach to landing attitude Examination of the accident site revealed that the airplane impacted soft terrain about 390 feet short of the approach end of runway 15 slightly left of the runway All major structural components of the airplane were located within about 30 feet of the main wreckage The wreckage was recovered to a secure location for further examination Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 45 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt WPR12LA414 08 17 2012 1425PDT Regis N6493N Bakersfield CA Apt Meadows Field Airport BFL Acft Mk Mdl CESSNA T210N Acft SN 21063067 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl CONT MOTOR TSIO 520 SER AcftTT 3950 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name EAGLE CAP LEASING INC Opr dba Aircraft Fire IFLT Narrative HISTORY OF FLIGHT On August 17 2012 about 1425 Pacific daylight time a Cessna T210N N6493N experienced an in flight fire shortly
127. e Federal Aviation Administration FAA revealed that the airplane was at an altitude of 6 000 feet and 8 miles northeast of M04 when the pilot reported the destination airport in sight and cancelled his IFR clearance The controller then issued the airplane a frequency change to the M04 common traffic advisory frequency CTAF There were no further communications from the accident airplane In a telephone interview the airport manager stated he was monitoring the CTAF when the accident pilot announced he was 7 5 miles from the airport and in bound for landing The manager recognized the pilot s voice as they had spoken by telephone the previous day and was aware of the pilot s plans upon arrival He advised the pilot that parking fueling of his airplane and ground transportation had been arranged Approximately 2 minutes later the pilot announced over the radio that he was out of fuel and putting the airplane down short of the airport The manager stated there were no further radios transmissions from the accident airplane The pilot held a private pilot certificate with ratings for airplane single engine land and instrument airplane His most recent FAA second class medical certificate was issued March 26 2014 According to club records the pilot had accrued approximately 242 hours of flight experience of which 178 hours were in the accident airplane make and model According to FAA records the airplane was manufactured in 1979 Its mos
128. e airplane impacted about two miles off the departure end of Runway 3 on the extended runway centerline The initial impact point included ground impressions from all three landing gear and was 440 feet from the furthest piece of wreckage The debris path was oriented on a 340 degree heading The engine and wings separated from the fuselage The fuselage was broken into three large sections the instrument panel with forward floor assembly the aft Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 27 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database seats with floor assembly and the empennage The fuselage sections remained loosely connected via the flight control cables The engine came to rest 60 feet in front of the fuselage Control cable continuity was established for all flight control surfaces through tension overload separations in the front door posts and at the wing roots Both propeller blades displayed twisting S bending deformation and chordwise scratches The sparkplugs exhibited normal wear when compared to the Champion Aviation Check a Plug Chart AV 27 and both magnetos were capable of producing spark The crankshaft was rotated by hand and thumb compression was established on all cylind
129. e blade was displaced aft about the mid span and was bowed up 3 feet inboard from the tip There was a compression wrinkle on the upper surface 6 feet 8 inches inboard from the rotor tip The leading edge of the upper surface exhibited chord wise scratches from the tip inboard to 7 feet that corresponded to a ground scar in the asphalt at the crash site The upper skin was delaminated from the root of the rotor to 9 feet outboard Upward bending started 14 feet inboard of the blade tip The spindle was connected and rotated roughly The upper swash plate fork remained connected to the swash plate The yolk remained connected to the fork by the dog bone The yolk was connected to the dog bone on both sides The yolk was fractured on the weighted sides and was recovered from the roof top of a building The weights were in place but damaged due to impact with the gravel roof of the industrial park building The tail boom exhibited a vertical scuff with white paint transfer 25 25 inches forward of the aft bulkhead adjacent to the tail rotor blade tip arch The intermediate flex coupling was deformed slightly but still connected There was rotational contact by the flex coupling with the upper frame The tail cone was severed by the main rotor system between bays five and six during flight and came to rest 275 M about 300 feet from the initial impact point The empennage remained attached to a 32 inch section of the tail boom and exhibited damage to the trailing e
130. e land and instrument airplane His most recent FAA second class medical certificate was issued on July 6 2011 He reported 155 total hours of flight experience 76 of which were in the accident airplane make and model The flight instructor in N602FT held a commercial pilot certificate with ratings for airplane single engine land multi engine land and instrument airplane He also held a flight instructor certificate with ratings for airplane single engine and instrument airplane His most recent FAA first class medical certificate was issued on June 1 2011 He reported 782 total hours of flight experience 738 of which were in single engine airplanes AIRCRAFT INFORMATION Both airplanes involved in the accident were single engine four seat low wing monoplanes of conventional metal construction They were powered by carbureted 160 horsepower four cylinder air cooled direct drive engines Their wings were of an all metal stressed skin fully cantilevered design consisting of two wing panels bolted to a spar box assembly in the fuselage The ailerons were controlled through cables and pushrods and were dynamically balanced The trailing edge wing flaps were manually operated Their empennages consisted of a vertical stabilizer rudder dynamically balanced stabilator and stabilator trim tabs Their tricycle type landing gear was of a fixed type and consisted of shock absorbing air oil type oleo struts Their two main landing gear whee
131. e muffler the cone was free to move around within the muffler assembly The other cone had a hole eroded in its center Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 43 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database ADDITIONAL INFORMATION The FAA Publication Aviation Maintenance Technician Handbook Powerplant Volume 1 Chapter 3 describes induction and exhaust systems One section of that chapter discusses internal muffler failures It states that internal failures baffles diffusers etc can cause partial or complete engine power loss by restricting the flow of the exhaust gases If pieces of the internal baffling break loose and partially or totally block the flow of exhaust gases engine failure can occur Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 44 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt WPR14FA186 05 10 2014 1545MST Regis N7311U Page AZ Apt Page Muni PGA Acft Mk MdI CESSNA T207A Acft
132. e of the right wing midspan A 6 inch long section of one propeller blade tip was missing and the spinner sustained crush damage and a black paint transfer next to the back plate During the forced landing the airplane sustained substantial damage to the wingtips firewall and the fuselage just aft of the left wing trailing edge The helicopter sustained damage during the collision sequence limited to the forward right skid and the center section of the left skid which was not recovered The helicopter did not sustain damage during the collision which would have prevented normal flight The helicopter rolled over during the landing most likely because of the separated landing gear skids As it rolled the tailcone came away from the fuselage and the forward cabin struck the ground The landing light switch was found in the OFF position following the accident and subsequent testing revealed that the lamp was operational The rear white and right green navigation lamps illuminated when tested however the left red lamp did not light Examination of the filament revealed that it had broken away completely at both posts Additional Information FAA Order JO7110 65U prescribes air traffic control procedures and phraseology for use by persons providing air traffic control services According to the order Controllers are required to be familiar with the provisions of this order that pertain to their operational responsibilities and to exercise the
133. e overrun for runway 36 The pilot reported no mechanical issues with the airplane The FAA inspector reported the fuselage was buckled the empennage was bent down and the left wing upper skin was deformed Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 78 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt WPR13LA262 06 04 2013 930 PDT Regis N5808U Burlington WA Apt Skagit Regional Airport BVS Acft Mk Mdl PIPER PA 28 140 Acft SN 28 26637 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING 0 320 SERIES AcftTT 3479 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name MORRISSEY WILLIAM T TRUSTEE Opr dba Aircraft Fire NONE Narrative On June 4 2013 at about 0930 Pacific daylight time a Piper PA 28 140 N5808U was substantially damaged when it struck an airport sign following a loss of directional control during landing roll at Skagit Regional Airport Burlington Washington The private pilot the sole occupant was not injured The pilot owner was operating the airplane under the provisions of 14 Code of Federal Regulations Part 91 Visual meteorological conditions prevailed for the personal cross country flight which had originated from
134. e ramp At 14 15 the airplane was seen to reenter the parking ramp where it was parked in its previous position The student and instructor from the flight previous to the accident flight were observed to exit the airplane and walk back to the main hangar At 14 40 the student from the accident flight was observed walking from the main hangar to the airplane where he then began his preflight inspection while his instructor was engaged in conversation with another student at the entrance to the Madison Terminal At 14 48 55 the student was observed climbing up on the right wing to examine the right fuel tank At 14 51 the student was observed climbing up on the left wing to examine the left fuel tank At 1458 the instructor was observed to leave the main hangar walk out to the airplane and get in it At 15 02 07 the airplane s engine was observed to start At 15 04 the airplane was observed to exit the parking ramp turning south on taxiway A Parking Ramp Review of satellite imagery of the parking ramp at 139 revealed that the parking ramp at 139 was not level and that the pavement sloped downward towards the east Further review revealed that the west end of the parking ramp was approximately 8 feet higher in elevation than the east end Review of satellite imagery of the fueling pad also revealed that it sloped downward towards the east and an approximate difference in elevation of 1 foot existed between the east side of the fueling pad
135. eceived from him When the student pilot was asked what maneuvers she performed during her flight training she said that she did not know what the maneuvers were called The student pilot said she performed two stalls one of which was a major stall and she did not remember what the configuration of the airplane was when those stalls were performed She was asked if she had performed ground reference maneuvers during her flight training and said she did not know what a ground reference maneuver was and asked what it was An example of a tum about a point such as a tree or road intersection at a lower altitude was provided and she said that she had not performed that maneuver She said she performed a simulated engine out during her flight training The student pilot was asked if she had performed emergency procedures and she said that they had only discussed emergency procedures When the student pilot was asked if she performed go arounds during her flight training she responded by asking what a go around was When a go around maneuver was described to her she said she had performed go arounds The flight instructor stated that when the airplane landed he talked to her using a portable radio to tell her the second landing the accident landing was perfect and to perform one final landing The student pilot acknowledged ok and then the airplane veered off the left side of the runway Examination of the airplane by a Federal Aviation Administration
136. ed the engine back to 2 100 rpm and applied full carburetor heat and enriched the mixture Upon reaching 3 500 feet he pushed the carburetor heat off and the engine quit He said he reapplied the carburetor heat but the engine did not restart He advised ATC of the situation and received a heading to Sacramento Mather Airport KMHR the closest airport to his position He said he made the nearly 180 degree turn toward the airport and continued attempts to restart the engine Unable to restart the engine and apparent that he was not going to reach the airport the pilot attempted to land in soccer fields at Phoenix Park Fair Oaks He did not extend the retracted landing gear During the landing the airplane collided with a car trees and terrain The airplane sustained substantial damage to the wings and fuselage The pilot said he had not experienced any mechanical problems with the airplane prior to the accident On December 6 the airplane was examined at the accident site by an FAA air safety inspector and no mechanical anomalies were found An examination of the airplane s maintenance logbooks did not reveal any anomalies or unresolved discrepancies An examination of the recovered wreckage was conducted March 28 2014 by an NTSB air safety investigator The examination of the engine did not reveal any evidence of any preexisting mechanical malfunction that would have precluded normal operation A copy of the examination report is contained
137. ed the right wing He was unable to correct for the wind gust before the airplane departed the left side of the runway and descended into a drainage ditch The airplane lower fuselage and engine mount sustained substantial damage when the nose gear collapsed The pilot reported no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation At 0932 a local weather station located in Yuma Colorado reported the wind direction was from 001 degrees at 18 knots with 26 knot gusts The nearest aviation weather reporting station was at the Wray Municipal Airport 2V5 located about 25 miles east of the accident site At 0935 the 2V5 weather observing system reported wind from 340 degrees at 18 knots gusting 24 knots 10 miles visibility clear sky conditions temperature 23 degrees Celsius dew point 10 degrees Celsius and an altimeter setting of 29 70 inches of mercury Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 70 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt WPR11LA318 07 08 2011 1315PDT Regis N4901Z Frazier Park CA Apt Nia Acft Mk Mdl PIPER PA 22 108 Acft SN 22 8486 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Ca
138. en area to find a suitable landing spot The pilot stated that the grass appeared to be knee to hip height but he believed it was safe to land He set up for landing and on the landing rollout about 20 30 knots the left main landing gear wheel struck an unseen large embedded boulder that collapsed the left main landing gear The airplane s wing sustained substantial damage The pilot reported no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 65 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt WPR14CA152 03 30 2014 1015 Regis N1952P Wheatland WY Apt Nia Acft Mk Mdl PIPER PA 18A 105SPECIAL Acft SN 18 4178 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING 0 320 SERIES AcftTT 2022 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name ROBERT SHEPARD Opr dba Aircraft Fire NONE Narrative The flight instructor owner and pilot rated passenger departed the local airport in a tailwheel equipped airplane to inspect ranch property and livestock The flight instructor was in the rear seat of the tandem cockpit airplane The pilots planned t
139. en statement provided by the pilot to a Federal Aviation Administration inspector he performed a three point landing in the tailwheel equipped airplane The airplane bounced two times and then it veered to the right According to a written statement from the passenger the approach was normal but the problems started after touchdown The airplane tumed to the right the pilot initiated a go around however the left wing rose up and the airplane lost control to the right The airplane came to rest in the grass on the right side of the runway and incurred substantial damage to the firewall and fuselage A postaccident examination of the airplane revealed no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 64 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt WPR14CA109 01 25 2014 1700 MST Regis N9683P Willcox AZ Apt N a Acft Mk Mdl PIPER PA 18 150 A150 Acft SN 18 7509026 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING 0 320 SERIES AcftTT 3830 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name JOHN SMITH Opr dba Aircraft Fire
140. engine land and instrument airplane He held a third class medical certificate issued in July 6 2010 with the limitation that he must wear corrective lenses for near and distant vision No personal flight records were located for the pilot The IIC obtained the aeronautical experience listed in this report from an insurance application dated November 10 2010 The pilot reported a total time of 2 218 hours with 1 422 hours in the make and model AIRCRAFT INFORMATION The airplane was a Cessna P210 serial number P21000374 Logbooks were not recovered for the airframe or engine An insurance application dated November 10 2010 indicated a tachometer time of 509 0 hours and a Hobbs meter time of 592 2 hours The oil filter on the airplane had markings dated April 23 2011 that indicated a tachometer time of 2 411 1 hours and a Hobbs meter time of 1 936 4 hours The engine was a Continental Motors Inc CMI TSIO 520 P 5 serial number 278637 R METEOROLOGICAL CONDITIONS An automated surface weather observation at Tehachapi Municipal Airport KTSP elevation 4 001 feet msl was issued at 1115 PDT It indicated wind from Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 41 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Ac
141. ent pilot had amassed over 40 flight hours and was performing a local area practice flight During landing the airplane touched down hard and bounced several times down the runway surface During the accident sequence the airplane incurred substantial damage to the firewall The operator reported no pre impact mechanical malfunctions or failures that would have precluded normal operation Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS The pilot s inadequate landing flare which resulted in a bounced landing Events 1 Landing flare touchdown Hard landing Findings Cause Factor 1 Personnel issues Task performance Use of equip info Aircraft control Student instructed pilot C 2 Aircraft Aircraft oper perf capability Performance control parameters Landing flare Incorrect use operation C Narrative The operator stated that the student pilot had amassed over 40 flight hours and was performing a local area practice flight During landing the airplane touched down hard and bounced several times down the runway surface During the accident sequence the airplane incurred substantial damage to the firewall The operator reported no pre impact mechanical malfunctions or failures that would have precluded normal operation Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 17 Prepared From Official Records of the NTSB By All Rights Reserved A
142. ent stall during gust crosswind conditions Events 1 Approach VFR pattem final Loss of control in flight 2 Uncontrolled descent Collision with terr obj non CFIT Findings Cause Factor 1 Personnel issues Action decision Action Delayed action Pilot C 2 Environmental issues Conditions weather phenomena Wind Crosswind Contributed to outcome 3 Environmental issues Conditions weather phenomena Wind Gusts Contributed to outcome Narrative The pilot said he was attempting to land on runway 18 in variable crosswinds with gusty conditions There may have been wind shear or tailwinds involved He told a Federal Aviation Administration FAA inspector that the airplane stalled at low altitude 5 to 8 feet above the runway and landed hard on the overrun for runway 36 The pilot reported no mechanical issues with the airplane The FAA inspector reported the fuselage was buckled the empennage was bent down and the left wing upper skin was deformed Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 80 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt ERA12LA355B 05 22 2012 2200 EDT Regis N602FT Melbourne FL Apt Melbourne International MLB Acft Mk Mdl PIPER PA 28
143. er the son of both occupants reported the airplane was always kept in great Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 90 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database shape METEOROLOGICAL INFORMATION A surface observation weather report taken at Ocala Intemational Airport Jim Taylor Field OCF Ocala Florida at 1550 or approximately 22 minutes before the accident indicates the wind was from 180 degrees at 3 knots The visibility was 10 statute miles and scattered clouds existed at 4 000 and 5 500 feet The temperature and dew point were 32 and 23 degrees Celsius respectively and the altimeter setting was 30 04 inches of mercury The accident site was located approximately 4 nautical miles and 301 degrees from OCF WRECKAGE AND IMPACT INFORMATION The accident site consisted of an open field surrounded by trees The main wreckage was located at 29 degrees 12 minutes 26 02 seconds North latitude and 082 degrees 17 minutes 24 47 seconds West longitude while the outer section of the right wing was located at 29 degrees 12 minutes 24 46 seconds North latitude and 082 degrees 17 minutes 28 46 seconds West longitude or about about 390 feet and 245 degrees from the main wreckage location
144. ers Drive train continuity was established throughout the engine The cylinders were borescope inspected and no anomalies were noted The oil filter element was inspected with no contaminates noted Examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation MEDICAL AND PATHOLOGICAL INFORMATION On December 2 2013 an autopsy was performed on the pilot at the Montrose Memorial Hospital Montrose Colorado The examination determined the cause of death to be due to multiple traumatic injuries The FAA s Civil Aeromedical Institute in Oklahoma City Oklahoma performed a toxicology test on the pilot The test was negative for carbon monoxide and ethanol and drugs with the exception of Acetaminophen Tylenol ADDITIONAL INFORMATION The flight instructor CFI who flew most of the student s training flights characterized him as having very high achieving and performance traits He thought the student had a go go go type personality and led a fast paced life due to a hectic schedule managing a telecommunications business He was aware that his student was an accomplished motorcycle racer and avid motorcycle enthusiast The CFI stated the student intended to utilize the accident airplane to accomplish trips in support of his telecommunications business and was concerned that he might try to push too hard with respect to weather conditions fatigue or airplane maintenan
145. es Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database altitude of 1 200 feet This aircraft was not in communication with air traffic control and was later determined to be N433JC About 1842 the controller asked N7508Y how much further east she would be flying and the pilot responded We ll be over Antioch Bridge but be turning bound soon zero eight yankee The radar controller responded roger traffic one o clock 6 miles northbound altitude indicates two thousand six hundred appears level and the pilot replied zero eight yankee Fifty seconds later the controller advised the pilot that the target was now tuming northwest bound at a range of 4 miles and the pilot replied that she was turning northbound Immediately following this response an airplane with the call sign Cherokee 9808W called the approach controller requesting visual flight rules VFR flight following The controller confirmed contact and asked the Cherokee to standby Over the course of the next 73 seconds the controller corresponded multiple times with the Cherokee utilizing the call sign Cherokee 08W and 08W and a Piper Tomahawk call sign 11T Audio data revealed a beeping sound during the controller s transmissions which was consistent with an automatically generated aural conflict alert Radar playback data also revealed that at that time the controller was also receiv
146. evice was removed from the wreckage and was examined at the NTSB vehicle recorder division in Washington DC The flash memory device was missing and no data was recovered Vacuum Pump The vacuum pump and drive spline assembly were removed from the wreckage and examined at the NTSB materials laboratory in Washington DC Within the vacuum pump drive spline assembly the intemal shear coupler which connects the internal spline drive with the external spline drive exhibited thermal damage such as melting The thermal damage to the coupler material was consistent with continued engine rotation after the coupler fractured A fracture initiation location was found along an area where the reduced section of the inner coupler shaft meets a flange Under magnification some areas of flat fracture features were also noted that were consistent with a fatigue fracture however missing material and the thermal damage to the existing shaft material prevented a definitive determination of the failure mode Directional Gyro and Attitude Gyro Portions of the directional and attitude gyros were removed from the wreckage and examined at the NTSB materials laboratory in Washington DC The directional gyro did not exhibit circumferential scoring The inside of the gyro contained impressions on the case The attitude gyro exhibited circumferential scoring on both the case and gyro ADDITIONAL INFORMATION According to FAA Advisory Circular 60 4A Pilot s Spatial
147. feet Radar contact was then lost WRECKAGE AND IMPACT INFORMATION The main wreckage impacted on a rock exposed area in remote rolling terrain at an estimated elevation of 1 507 feet above mean sea level msl The impact crater and damage to the airframe was consistent with a nearly vertical impact angle There was evidence of a fuel spill at the scene however there was no postimpact fire The airframe was compressed from the engine aft to the empennage area with extensive fragmentation of many of the parts The attitude of the airframe at the time of impact was also confirmed by an impact depression of the left wing and wingtip in the ground Evidence of ground impact was noted on the stabilator balance tube displacing the balance weight aft on the tube and cutting one of the primary cables All major components at the main wreckage showed evidence of impact crushing damage The left wing was fragmented and was found at the main crash site with the left flap and aileron The leading edge displayed compression impact damage along the entire leading edge that penetrated aft to the trailing edge of the wing The position of the flap as indicated by the wing trailing edge impression on the flap was consistent with a retracted position The aileron control and balance cables were both secure to the bellcrank but the attach fitting was impact broken and the cables were pulled inboard The balance cable was continuous to the right side and the control ca
148. found to be broken All of the breaks were similar to the fatigue fracture breaks found when examining the right rudder cable The exit of the S tube where the right rudder cable break was located had wear damage consistent with the diameter and location of the rudder cable The S tube was welded to the side of the rudder pedal and had cut ends that were not flared A mockup of the rudder system revealed that with the rudder deflected fully forward the cable was forced to make a sharp bend at the forward exit of the S tube Additionally the wear pattern noted on the S tube was consistent with the position of the cable during full deflection Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 59 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database After the accident the owner of an exemplar glider N6OVR examined the rudder control cables on his glider and found that the cables had damage in the same location as on N555AP The owner of N60VR elected to conduct ground based testing to determine the progressive nature of the rudder cable damage While in a normal seating position wearing a backpack parachute the rudder pedals were cycled in one minute intervals with an observation period between cycles The
149. fter she sighted a silhouette of the airplane and propeller at her 4 o clock position She performed an evasive maneuver to the left but then felt the helicopter being struck Neither the airplane pilot nor the occupant observed another aircraft near the airplane before the collision Although the airplane pilot was not receiving traffic advisories from ATC it was still the pilot s responsibility to maintain a proper visual lookout to avoid other aircraft in the area The helicopter s left navigation light was inoperative when tested after the accident however this most likely did not affect the outcome because the left side of the helicopter would not have been visible to the airplane pilot at any point during the flight Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS The failure of both pilots to see and avoid the other aircraft during cruise flight Contributing to the accident was the failure of air traffic control personnel to issue the helicopter pilot with a prompt and appropriate alternate course of action upon receiving a conflict alert Events 1 Enroute cruise Midair collision 2 Emergency descent Collision with terr obj non CFIT Findings Cause Factor 1 Personnel issues Psychological Attention monitoring Monitoring other aircraft Pilot C 2 Personnel issues Action decision Action Lack of action ATC personnel F Narrative HISTORY OF FLIGHT On February 19 2
150. g Mk Mdl LYCOMING 0 540 SERIES AcftTT 4857 Fatal 2 Serlnj 0 Fit Conducted Under FAR 091 Opr Name DALE L PHILLIPS JR Opr dba Aircraft Fire NONE Narrative HISTORY OF FLIGHT On February 20 2012 about 1936 central standard time a Piper PA 24 250 single engine airplane N7147P impacted terrain near Albany Texas The private pilot and passenger were fatally injured The airplane was substantially damaged The airplane was registered to Baga Air Inc and operated by a private individual under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight Dark night visual meteorological conditions prevailed and no flight plan was filed The flight departed Abilene Regional Airport ABI Abilene Texas at 1920 and was destined for the University of Oklahoma Westheimer Airport OUN Norman Oklahoma The airplane had climbed to cruise altitude and was level at 9 500 feet mean sea level msl About three minutes later the pilot made a radio call that he needed to return to ABI because he had lost suction and his attitude indicator The controller cleared the airplane to return to ABI Radar data showed the airplane made a climbing tum to the right and the airplane then descended rapidly Radar and radio contact was lost about 1936 The wreckage was found the next morning Ground and airplane impact signatures showed evidence of a nearly vertical nose down collision with terrain The outboard section of the right wing and the right a
151. gh the canyon the day before with his instructor The pilot stated that about halfway through the canyon the helicopter dropped about 100 feet at which time he observed the main rotor revolutions per minute rpm were between 80 to 85 percent The pilot reported that he then lowered the collective and rolled on throttle maintained 70 knots and turned towards a field During the tum the rpms came up to about 90 percent and after leveling out the rpms dropped back to between 80 to 85 percent The pilot said that after he cleared a set of wires he set up to land in the field The pilot added that he did a baby flare at the bottom then a full flare before adding a little pitch and setting the helicopter down The pilot stated that after setting down it felt like my front skid caught which tipped me and the helicopter onto its left side As a result of the rollover the helicopter s structure sustained substantial damage The pilot reported no preimpact mechanical malfunctions or failures with the helicopter that would have precluded normal operation A postaccident inspection of the engine was performed by a Federal Aviation Administration airworthiness inspector The inspector stated that prior to performing an engine run the sparkplugs for cylinders 1 3 and 5 were removed and drained of oil the inspector speculated that the oil contamination had occurred during the shipment of the helicopter to the examination testing facility The inspector re
152. gle engine airplane instrument and airplane multi engine The flight program was administered by two associate professors the director of aviation chief pilot and an assistant chief pilot and all training was conducted in accordance with 14 CFR Part 141 Before graduation students would accrue approximately 250 to 300 flight hours Fueling operations were administered by the airport manager and maintenance operations were administered by an aircraft maintenance manager instructor pilot ADDITIONAL INFORMATION In order to increase safety Eastern Kentucky University EKU took the following actions 1 On April 20 2012 EKU s fixed base operation s fuel processes were modified to track fuel purchase by aircraft registration number allowing them to determine the actual amount of fuel uploaded to each individual aircraft 2 The owner of the university s aircraft assured that the correct dipsticks i e 19 gallon factory calibrated dipsticks for all of their Cessna 172Ps factory calibrated 26 5 gallon dipsticks for all their Cessna 172Rs and universal dipsticks for their C172RGs and their Piper Seneca were provided to EKU They also assured that the universal dipsticks were calibrated using the factory provided calibration cards and instructions All of the dipsticks have also been marked with the corresponding registration number and placed in their respective aircraft 3 The maintenance provider modified their standard operating procedures
153. h the engine running Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 85 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt ERA14LA227 05 07 2014 1107 CDT Regis N4506W Covington TN Apt Covington Muni M04 Acft Mk Mdl PIPER PA 28 181 Acft SN 28 8090028 Acft Dmg DESTROYED Rpt Status Prelim Prob Caus Pending Eng Mk Mdl LYCOMING 0 amp VO 360 SER AcftTT 7945 Fatal 0 Serlnj 1 Fit Conducted Under FAR 091 Opr Name DAYTON PILOTS CLUB INC Opr dba Aircraft Fire NONE Narrative On May 7 2014 at 1107 central daylight time CDT a Piper PA 28 181 N4506W operated by the Dayton Pilots Club Inc was destroyed when it collided with wooded terrain during a forced landing following a total loss of engine power on approach to Covington Municipal Airport M04 Covington Tennessee The certificated private pilot was seriously injured Visual meteorological conditions VMC prevailed and an instrument flight rules IFR flight plan was filed for the flight that departed Dayton Wright Brothers Airport MGY Dayton Ohio about 0710 CDT The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91 Preliminary air traffic control information from th
154. hat they were going to make a high wind landing The passenger stated he crouched down in the basket for the landing and as the triangular basket touched down and turned to its flat side he felt his ankle roll The basket lay down and once the balloon stopped they crawled out of the basket The passenger stated he knew he injured his ankle and a couple days later he was diagnosed with a fractured tibia Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 55 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt WPR11LA306 07 05 2011 1050PDT Regis N1334R Yacoit WA Apt N a Acft Mk Mdl GRUMMAN AMERICAN AVN CORP AA 5 Acft SN AA5 0734 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING 0 320 C2G AcftTT 2926 Fatal 0 Serlnj 2 Fit Conducted Under FAR 091 Opr Name STEVEN L EMERSON Opr dba Aircraft Fire NONE Summary The pilot reported that the airplane was climbing to cruise altitude up a valley in mountainous terrain when he felt a small bump and that the airplane subsequently began descending While maintaining a low altitude to avoid overlying controlled airspace he initiated a left tum to avoid rising terrain ahead but a wing collided with a tree The
155. hat a large fir tree was in the airplane s path he stated that the airplane had about 1 000 feet of clearance above the tree s elevation prior to the bump He started a gentle 4 degree bank tum to avoid the tree The airplane descended until the right wing collided at midspan with a smaller unseen tree The airplane came to rest in a gravel pit Both the pilot and passenger sustained broken legs and lacerations the pilot sustained broken fingers on his right hand as well which he attributed to his maintaining the full throttle position until touchdown The pilot stated that his preflight forecast was for calm conditions to 6 000 feet and he did not encounter any turbulence during the flight The Federal Aviation Administration FAA accident coordinator interviewed a bystander who came to the aid of the airplane s occupants The bystander arrived about 5 minutes after the crash he observed one person with a shattered ankle standing by the left side of the airplane and one person still in the right seat Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 56 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database He noted that he saw a small fuel leak from under the left wing and there was a fuel odor Two
156. he airplane subsequently overran the end of the runway and went through the perimeter fence After he exited the airplane the pilot found the flaps fully retracted The airplane s Pilot Operating Handbook stated that go arounds should be performed with the flaps at 20 degrees Further the pilot should have performed a go around when he first noticed that the airplane was too high and fast on the final approach Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS The pilot s delay in executing a go around which resulted in a runway overrun Contributing to the accident were the pilot s failure to establish the proper glidepath and airspeed on final approach and his improper use of flaps during the go around Events 1 Landing landing roll Runway excursion Findings Cause Factor 1 Personnel issues Action decision Action Delayed action Pilot C 2 Personnel issues Task performance Use of equip info Use of policy procedure Pilot F 3 Aircraft Aircraft oper perf capability Performance control parameters Descent approach glide path Not attained maintained F Narrative On August 31 2012 about 1610 mountain standard time a Cessna 182R N5458N sustained substantial damage during a runway overrun while landing at St Johns Arizona The private pilot the sole occupant received minor injuries The pilot owner was operating the airplane under the provisions of 14 Code of Federal Regulatio
157. he rudder pedal design configuration revealed that full forward deflection of the rudder pedal forced the cable to sharply bend at the point where it exited the forward opening of the S tube which was confirmed by a corresponding wear pattem on the accident gliders S tube The repeated bending during normal operation resulted in the fatigue failure of 92 percent of the individual right rudder cable wires and subsequently final overstress failure of the remaining wires After the accident the owner of another glider of the same design examined the rudder cable on his glider and found similar damage to the cable Subsequently he conducted ground testing which confirmed that repeated operation of the rudder pedals resulted in further damage to the rudder cables indicating a progressive failure Therefore it is likely that the right rudder cable failed during the flight and resulted in the loss of rudder control The glider manufacturer subsequently issued service bulletins and service letters to address the rudder pedal system deficiencies discovered during the accident investigation Flight testing conducted by the manufacturer in an exemplar glider confirmed that the glider would have been controllable if the pilot had not chosen to bail However the flight testing was conducted under controlled conditions and the test pilot was fully aware of the modifications made to the exemplar glider to simulate the cable failure Further despite these modifications
158. hibited chordwise scratching and leading edge gouging on its blades where they had come into contact with the left side of N602FT s stabilator Minor scratching was also present on the right wing where it had come in to contact with the right side of N602FT s stabilator Postaccident examination of N602FT revealed that it had sustained substantial damage where the propeller from N47749 had come into contact with the left side of the stabilator Multiple prop strike marks were present and approximately 2 feet of the left outboard section had been severed from the stabilator TESTS AND RESEARCH Application of Parking Brake in N47749 According to the private pilot in N47749 when he stopped at the runup area at the end of taxiway A there was approximately one aircraft length between his airplane and the airplane in front of him N602FT He thought he had set the parking brake because immediately after he stopped he grabbed the parking brake handle and pulled it back He advised however that it was not set He realized this after he struck N602FT At the time he had been trying to set 1 000 rpm on the tachometer At the time he thought that his feet were on the brake pedals He figured out that I did not put so much pressure on the brake pedals before the crash When he heard the crash he thought that the airplane in front of him had moved back and he immediately grabbed the parking brake and set it N47749 Brake System Examination Post
159. hiness Directive AD 2013 02 13 which was prompted by reports of cable assembly failures that led to failure of the horizontal stabilator control system and resulted in loss of pitch control This AD required inspection of the stabilator control system and replacement of parts as necessary According to FAA and airplane maintenance records the airplane was manufactured in 1979 The airplane had recently been purchased and was going to be placed in a local operator s fleet for rental and use in their pilot training program As part of the purchase it had undergone an annual inspection on July 21 2013 At the time of the inspection the airplane had accrued 6 100 3 total hours of operation At the time of the incident the airplane had 6 106 total flight hours According to the airframe and powerplant mechanic s logbook entry for the annual inspection Airworthiness Directive AD 2013 02 13 effective March 11 2013 had been complied with during the annual inspection by inspecting the cables in accordance with Piper Service Bulletin SB 1245A The inspection as described in SB 1245A required that the mechanic disassemble the turnbuckle assembly and clean it using a solvent such as acetone Use of a Scotch Brite general purpose green scouring pad was also permitted for cleaning A 10x magnifier a mirror and a suitable light source were then required to be used to inspect the turnbuckle terminal and adjacent segment of cable Any evidence of cracks cable
160. ht was to reposition the airplane to a nearby airport for an intended annual inspection The son of both occupants reported to either the Federal Aviation Administration FAA inspector in charge or the NTSB investigator in charge that he and his father who is not a certificated pilot inspected the airplane before he the son started the engine The son stated that he asked his father how much fuel was on board and he replied 13 gallons the son later reported that was more than adequate to complete the intended flight With his father seated in the front seat the son started the engine and reported the engine started right up After the engine was started a fuel leak at the carburetor was noted smoke was noted coming from the engine and it did not develop static maximum red line rpm This was attributed to the choke that was left on His mother then boarded the airplane and it was taxied to the runway where an engine run up lasting 5 minutes was performed The son reported the engine sounded OK and no discrepancies were reported After takeoff the son reported that his mother performed a low pass then the flight departed to the southeast The son also reported that personnel from the airport where his parents had intended flying arrived at the departure airstrip and inquired about his parents Law enforcement was then notified of the overdue airplane and a search was initiated There were no known witnesses to the accident which occurred during da
161. ian registry and imported into the United States after being purchased by a company headquartered in Texas On July 9 2003 it was sold to the owner who was in possession of the airplane at the time of the accident On April 30 2007 it was involved in a previous accident in Livermore Califonia SEAO07CA120 when the airplane impacted a runway in a nose low attitude and incurred substantial damage to the firewall The airplane s most recent annual inspection was completed on March 20 2012 At the time of the inspection the airplane had accrued approximately 6 040 total hours of operation METEOROLOGICAL INFORMATION The reported weather at 139 at 1555 included winds 060 degrees at 3 knots 10 miles visibility sky clear temperature 22 degrees C dew point 05 degrees C and an altimeter setting of 30 01 inches of mercury WRECKAGE AND IMPACT INFORMATION Examination of the accident site revealed that during the emergency landing the airplane struck powerlines before touching down in a field of knee high grass After touchdown the airplane traveled approximately 510 feet on an approximate 180 degree magnetic heading before cresting a hill impacting a tree with the right wing pivoted 180 degrees traveling backward down the hill and coming to rest 670 feet from where it touched down Evidence of braking was visible for approximately the first 40 feet Examination of the wreckage by an FAA inspector revealed no evidence of any preimpact mecha
162. ich calculated to a 8 524 foot density altitude The engine was shipped to Continental Motors Inc and on March 27 2013 it was examined in the presence of a National Transportation Safety Board investigator No evidence of any pre impact mechanical discrepancies was found with the engine that would have prevented normal operation Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 29 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt WPR12LA384 08 31 2012 1610 MST Regis N5458N St Johns AZ Apt St Johns Industrial Air Park SJN Acft Mk Mdl CESSNA 182R Acft SN 18267729 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl CONT MOTOR 10 470 SERIES AcftTT 2359 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name BRUCE D LISLE Opr dba Aircraft Fire NONE Summary The pilot reported that the airplane was high and fast on final approach for landing so he lowered the flaps to 40 degrees and raised the nose to slow down The pilot then decided to go around so he applied full power and raised the flaps to 30 degrees The airplane began to climb but then it started descending The pilot reduced the engine power landed the airplane and applied heavy braking T
163. ies of exchanges with various local law enforcement agencies and airport managers throughout the Cody and Twin Falls area On May 10 still unable to locate the occupants family members contacted Lockheed Martin Flight Services and an Alert Notice ALNOT was issued Utilizing radar data provided by the Air Force Rescue Coordination Center search and rescue personnel from the Park County Office of Homeland Security were able to visually locate the airplane by helicopter in the Shoshone National Forest As of the publication of this report due to the inhospitable nature of the terrain the accident site was inaccessible to both NTSB and search and rescue personnel Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 61 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt WPR12LA382 08 31 2012 1050PDT Regis N132PC Chelan WA Apt N a Acft Mk Mdl MOONEY M20J Acft SN 24 0541 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING 10360 SER AcftTT 3140 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name HARSHMAN MAX M Opr dba Aircraft Fire NONE Summary The pilot reported that after departure and during the climb the engine suddenly stopped producing
164. ileron were found about one mile southeast from the main wreckage PERSONNEL INFORMATION The pilot age 48 held a private pilot certificate with a rating for airplane single land which was initially issued on April 10 2007 He was most recently issued a third class airman medical certificate with limitations on May 10 2010 The pilot s logbook showed entries beginning on June 7 1994 with the last entry on February 1 2012 An endorsement showed a flight review was completed on July 25 2011 and a high performance endorsement was entered on December 4 2008 A review of the logbook showed that that pilot had logged 502 0 hours of total flight experience in single engine airplanes with about 186 hours of flight experience in Piper PA 24 airplanes The pilot had logged 68 0 hours of night flight experience During the previous 15 flights logged between ABI and OUN 12 of the flights were logged as night flights The pilot had logged a total 3 6 hours of flight instruction in simulated instrument conditions The logbook did not contain a listing of any instrument flights more recently than December 31 2006 AIRCRAFT INFORMATION The four seat low wing retractable landing gear single engine airplane serial number s n 24 2312 was manufactured in 1960 It was equipped with a 250 horsepower Lycoming mode O 540 E4B5 engine s n L 20394 40A which drove a Hartzell model HC C3YR 1RF 3 blade metal alloy propeller s n DY 4365 A A review
165. ilot rated passenger flew through a canyon the airplane gained airspeed and altitude As they continued toward their destination the flight instructor directed the pilot to turn right at a branch in the canyon Shortly after the terrain elevation increased and it exceeded the airplane s climb performance and the airplane subsequently impacted trees The density altitude for the area was calculated to be about 8 524 feet which would have affected the airplane s climb performance A postaccident examination of the engine revealed no evidence of mechanical malfunctions or failures that would have prevented normal operation Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS The flight instructor s selection of the wrong route while flying in mountainous terrain at a high density altitude which resulted in the airplane impacting terrain when the increase in elevation exceeded the airplane s climb performance Events 1 Enroute climb to cruise Controlled flight into terr obj CFIT Findings Cause Factor Personnel issues Action decision Info processing decision Decision making judgment Instructor check pilot C Aircraft Aircraft oper perf capability Aircraft capability Climb capability Capability exceeded C Environmental issues Physical environment Terrain High elevation Contributed to outcome Environmental issues Conditions weather phenomena Temp humidity pressure High density altitude C
166. ilot reported that while in flight at about 11 300 feet above mean sea level msl he heard a loud metallic noise from the area near the rudder pedals and lost contact between his feet and the rudder pedals The pilot stated that he thought that the pedal adjustment mechanism had given way and attempted to adjust the pedals through the use of the adjustment handle When he pulled on the adjustment handle it had no tension and did not retract as designed He maintained partial control of the glider using aileron and elevator control however the glider was descending in a right yaw condition When the glider had descended to about 10 000 feet msl the pilot elected to bail out because the surrounding terrain was unfavorable for a forced landing The glider was equipped with a Clear Nav global positioning system GPS receiver The data downloaded from the receiver depicted the entire accident flight The data showed the glider was heading north northeast when it made a climbing left tum of about 360 degrees During the 40 second turn the average rate of climb was calculated to be 388 feet per minute After the completion of that turn at 1904 40 the glider was about 11 538 feet GPS altitude As the glider Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 58 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety
167. imeter setting The pilot restated her call sign and the controller responded now utilizing 08Y expounding that her transmissions were fairly scratchy and hard to read She was provided with a transponder code and the flight continued uneventfully for the next 6 minutes after which time the controller asked her to contact Travis approach At approximately 1832 the pilot made contact with Travis approach utilizing the call sign Helicopter 7508Y The controller replied with the call sign of 08W while asking her to verify altitude The pilot responded with an altitude of 3 000 feet and restated her call sign as 08Y and again the controller replied with the incorrect call sign The pilot retransmitted the correct call sign and over the next few exchanges the discrepancy was resolved and the controller responded with the correct call sign At 1838 the controller once again utilizing the incorrect call sign of 08W provided a traffic advisory to the helicopter pilot regarding a twin Cessna airplane The pilot replied stating is that for 08Y and the controller replied in the affirmative now utilizing the O8Y call sign Ninety seconds later the controller gave a second advisory stating that the Twin Cessna was at her 12 o clock position southwest bound and at 3 900 feet A few seconds after that the controller reported that the traffic was no longer a factor and the helicopter continued uneventfully Approximately 1840 a target appe
168. in the public docket for this accident Given the weather conditions at the time of the event and consulting a Carburetor Icing Chart it is unlikely carburetor ice was responsible for the engine s loss of power Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 67 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt CEN14CA227 05 02 2014 1700 CDT Regis N7308P New Braunfels TX Apt N a Acft Mk Mdl PIPER PA 24 250 250 Acft SN 24 2483 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING 0 540 SERIES Fatal 0 SerlInj 0 Fit Conducted Under FAR 091 Opr Name ANDERSON AVIATION Opr dba Aircraft Fire NONE Narrative The pilot with three passengers planned to depart and retum on a cross country flight The pilot stated that the airplane s left fuel tank was filled to an inch below the collar and the right fuel tank was filled to two inches below the collar He estimated that the airplane had 40 45 gallons of fuel on board with a planned en route time of 57 minutes and about a 10 knot tailwind Once at a cruise altitude of 7 500 feet he set the manifold pressure at 21 inches and engine rpm at 2 300 for a fuel burn of 12 3 gallons hr per the pilot operati
169. indicated that 58 gallons had been consumed since the previous refueling which left about 16 gallons of usable fuel remaining At that time the pilot estimated that the airplane was about 5 Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 34 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database minutes from its destination and therefore he had more than sufficient fuel to reach the destination When the engine quit the pilot was of the mindset that he did not have a fuel problem He did not refer to any emergency procedures checklists subsequent to the power loss The third entry in the Engine Failure During Flight checklist in the Emergency Procedures section of the airplane manufacturer s Pilot s Operating Handbook was Fuel Selector Valve BOTH The pilot stated that it was his habit pattern to operate the airplane with the fuel selector set to the BOTH position When the airplane was righted the day after the accident and the pilot saw that the fuel selector was set to the left tank he recalled that at some point during the flight he had moved the fuel selector from BOTH to LEFT in order to correct a fuel imbalance with the intention of resetting it to BOTH once the imbalance had been correc
170. ing a visual alert on the radar console During that period the Travis Approach Radar Assist controller Radar Associate Position received a land line interphone call from a NORCAL approach controller who had also received the alert and was concemed about the proximity of N7508Y and N433JC The assist controller responded yeah we re givin him traffic Radar data indicated that the helicopter and N433JC were now at the same altitude of 2 600 feet within 1 mile of each other and closing The Travis Approach controller then transmitted Zero eight yankee traffic now twelve o clock less than a mile east correction westbound two thousand six hundred indicated A few seconds later the radar targets merged and the pilot of N7508Y transmitted MAYDAY MAYDAY HELICOPTER GOING DOWN Examination of the radar data revealed that the helicopter s mode C reported altitude varied between 2 600 and 3 300 feet during the period it was receiving flight following No other targets were observed in close proximity to the two aircraft leading up to the collision Interpretation of the voice recordings revealed that although the helicopter pilot always reported her correct call sign background noise and the inflection of her voice often resulted in the last digit yankee sometimes sounding like whiskey Airframe Examinations Postaccident examination of the airplane revealed that a forward portion of helicopter s right skid had become lodged in the leading edg
171. inued if two reinforcement doublers were fabricated and welded to the rudder bar in the affected area There were no reinforcement doublers on the airplane s rudder bar Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 79 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt CEN14CA203 04 19 2014 1236 EDT Regis N38240 Kalamazoo MI Apt Newman s Airport 4N0 Acft Mk Mdl PIPER PA 28 140 Acft SN 28 7725271 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING 0 320 E2D AcftTT 4154 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name ROBERT I GOODWIN Opr dba ADVENTURE AIR AVIATION Aircraft Fire NONE Summary The pilot said he was attempting to land on runway 18 in variable crosswinds with gusty conditions There may have been wind shear or tailwinds involved He said the airplane stalled at low altitude 5 to 8 feet above the runway and landed hard on the overrun for runway 36 The pilot reported no mechanical issues with the airplane The fuselage was buckled the empennage was bent down and the left wing upper skin was deformed Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS An inadvert
172. ir Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt ERA12LA294 04 19 2012 1600 EDT Regis N28BC Richmond KY Apt Madison Airport 139 Acft Mk Mdl CESSNA 172R Acft SN 17280901 AcftDmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING I0 360 L2A AcftTT 6040 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name EASTERN KENTUCKY UNIVERSITY Opr dba Aircraft Fire NONE Summary The flight instructor reported that after getting in the airplane he asked the student pilot how much fuel was in each tank The student pilot replied that 21 5 gallons of fuel were in one tank and 20 gallons of fuel were in the other tank The student pilot reported dipping a fuel stick into the fuel tanks during the preflight to check the fuel levels Although the flight instructor noticed that the fuel quantity indicators showed that 20 gallons of fuel were in one tank and 15 gallons of fuel were in the other tank he did not question the fuel discrepancy A review of security camera video revealed that the flight instructor did not supervise the student pilot s preflight inspection nor conduct a walk around inspection After departure the student pilot flew the airplane to another airport for a short and soft field training lesson After 45 minutes of training they departed for their home airpor
173. ir best judgment if they encounter situations that are not covered by it The order contains the following applicable excerpts Section 2 1 1 ATC SERVICE The primary purpose of the ATC system is to prevent a collision between aircraft operating in the system and to organize and expedite the flow of traffic and to provide support for National Security and Homeland Defense In addition to its primary function the ATC system has the capability to provide with certain limitations additional services The ability to provide additional services is limited by many factors such as the volume of traffic frequency congestion quality of radar controller workload higher priority duties and the pure physical inability to scan and detect those situations that fall in this category It is recognized that these services cannot be provided in cases in which the provision of services is precluded by the above factors Consistent with the aforementioned conditions controllers must provide additional service procedures to the extent permitted by higher priority duties and other circumstances The provision of additional services is not optional on the part of the controller but rather is required when the work situation permits Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 98 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2
174. irst class medical certificate was issued on January 13 2012 He reported that he had accrued 17 total hours of flight experience AIRCRAFT INFORMATION The accident aircraft was a high wing strut braced four place single engine airplane of conventional construction It was powered by a 160 horsepower four cylinder fuel injected engine It was certificated for flight in instrument meteorological conditions and was equipped with analog instruments with all of the flight instruments contained in a single panel located in front of the pilot These instruments were designed around the basic T configuration A fuel quantity indicator was located just to the left of the flight instruments and a Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 19 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database multi function annunciator was located above the altimeter It provided caution and warning messages for fuel quantity oil pressure low vacuum and low voltage situations According to FAA and airplane maintenance records the airplane was manufactured in 2000 and was delivered to an owner in Canada where it carried the Canadian registration of C GGPN On September 27 2002 it was removed from Canad
175. iway Charlie and Alpha He then began to taxi N47749 to the assigned runway He was number three for departure behind N602FT which was stopped behind a Cessna which was also operated by the flight school and was first for departure He stopped behind N602FT and set the parking brake and then looked at the tachometer to set 1 000 revolutions per minute rpm The airplane then slowly moved forward and struck N602FT PERSONNEL INFORMATION According to Federal Aviation Administration FAA and FIT Aviation records the private pilots in both airplanes were enrolled in FIT Aviation s commercial pilot Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 82 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database certification course The flight instructor in N602FT was employed by FIT Aviation The private pilot in N47749 held a private pilot certificate with a ratings for airplane single engine land and instrument airplane His most recent FAA second class medical certificate was issued on June 30 2011 He reported 137 total hours of flight experience 46 of which were in the accident airplane make and model The private pilot in N602FT held a private pilot certificate with a ratings for airplane single engin
176. kload traffic volume the quality limitations of the radar system and the available lead time to react are factors in determining whether it is reasonable for the controller to observe and recognize such situations While a controller cannot see immediately the development of every situation where a safety alert must be issued the controller must remain vigilant for such situations and issue a safety alert when the situation is recognized 2 Recognition of situations of unsafe proximity may result from MSAW E MSAWILAAS automatic altitude readouts JO 7110 65U 2 9 12 b Aircraft Conflict Mode C Intruder Alert Immediately issue initiate an alert to an aircraft if you are aware of another aircraft at an altitude which you believe places them in unsafe proximity If feasible offer the pilot an alternate course of action c When an alternate course of action is given end the transmission with the word immediately Section 2 4 15 EMPHASIS FOR CLARITY Emphasize appropriate digits letters or similar sounding words to aid in distinguishing between similar sounding aircraft identifications Additionally a Notify each pilot concerned when communicating with aircraft having similar sounding identifications b Notify the operations supervisor in charge of any duplicate flight identification numbers or phonetically similar sounding call signs when the aircraft are operating simultaneously within the same sector Printed May 22 2014 an airsafety
177. l wheels brakes tires etc The inspector stated that all maintenance work must be entered and the authorizing mechanic must ensure that such entries are made Post accident fire damage of the airplane precluded examination of the brake and landing gear systems Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com Page 1 National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt WPR12LA109B 02 19 2012 1845 PST Regis N433JC Antioch CA Apt Byron C83 Acft Mk Mdl BEECH 35 A33 Acft SN CD 351 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl CONT MOTOR 10 470 SERIES AcftTT 4830 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name RONALD A GAWER Opr dba Aircraft Fire NONE AW Cert STN Summary The helicopter and airplane collided midair Both aircraft sustained minimal damage during the impact but substantial damage during the subsequent forced landings The airplane pilot was performing a local flight and was not in contact with air traffic control ATC before the collision The helicopter pilot was receiving visual flight rules flight following services from ATC throughout the flight The helicopter pilot transitioned between two ATC sectors before the accident
178. l Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Incident Rpt ERA131A396 08 31 2013 1345 EDT Regis N2091W Chesapeake VA Apt Hampton Roads Executive PVG Acft Mk Mdl PIPER PA 28RT 201 Acft SN 28R 7918076 Acft Dmg NONE Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING I0 360 C1C6 AcftTT 6106 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name CCM INC Opr dba Aircraft Fire NONE Narrative On August 31 2013 about 1345 eastern daylight time a Piper PA 28RT 201 N2091W experienced a pitch control failure during takeoff at Hampton Roads Executive Airport PVG Chesapeake Virginia The airplane was undamaged and the two pilots were uninjured Visual meteorological conditions prevailed and no flight plan was filed for the local flight which was operated under the provisions of Title14 Code of Federal Regulations Part 91 According to the pilots the purpose of the flight was to familiarize themselves with the airplane During takeoff as they increased the angle of attack to become airborne they heard a loud pop and lost pitch control The airplane became airbome momentarily and then touched down on the runway in a three point attitude Neither of the pilots was injured and the airplane was undamaged Examination of the airplane revealed that the aft lower stabilat
179. l aviation 3 percent were commercial 1 percent were air taxi and 1 percent were military Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 83 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database There were 248 aircraft based at the field of which 190 were single engine airplanes 40 were multi engine airplanes 6 were helicopters and 1 was military The airport had three runways 9R 27L 9L 27R 05 23 At the time of the accident runway 9R was in use Review of published information and images of taxiway A which was the parallel taxiway for runway 9R and the runup area at the approach end of runway 9R revealed that there were no taxiway edge markings The taxiway centerline markings were in good condition the enhanced taxiway centerline markings prior to the runway holding position markings were in good condition and the holding position markings were in good condition The taxiway edge lighting was functional the taxiway location signs were functional the runway location signs were functional and the runway safety area hold short signs were functional WRECKAGE AND IMPACT INFORMATION Postaccident examination of N47749 revealed that it had sustained minor damage The propeller ex
180. lant fracture was observed near the outer surface Slant fracture was also observed at the inner edge of the band across most of the spot weld except for an area near the middle of the weld that appeared to have a granular appearance but was not in the transverse plane Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 46 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database A piece of the band containing the t bolt side of the fracture was separated from the rest of the clamp by cutting the band at the wrap for the t bolt assembly The flat fracture region had an intergranular appearance mixed with ductile tear ridges A piece of the band away from the fracture was cut to facilitate hardness testing The testing did not reveal any anomalies No part number or identifying information was found on the v band clamp According to the Parts Catalog for the Cessna model 210 and T210 airplanes one of two part number clamps may be used Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 47 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety co
181. lations CFR Part 91 The private pilot and one passenger sustained minor injuries the airplane sustained substantial damage from impact forces The personal cross country flight departed Hesperia about 1855 with a planned destination of Adelanto Califomia Visual meteorological conditions prevailed and no flight plan had been filed The pilot stated that he had flown to Hesperia from Adelanto earlier that evening and purchased about 29 gallons of fuel During the climb to cruise the airplane was unable to climb and the pilot turned back toward the airport He flew into a valley and realized that the airplane would not make it back to the airport He saw power lines in his flight path and tumed toward an open field The airplane hit the ground hard and then a tree which separated the right wing from the airframe Fuel spray from the wing set a car on fire The airplane spun around and came to rest with the nose on the ground and the left wing and tail resting against a house TESTS AND RESEARCH Investigators examined the wreckage at Aircraft Recovery Service Littlerock Califomia on July 14 2011 A detailed report is part of the public docket for this accident Examination of the airframe and engine revealed no anomalies that would have precluded normal operation Investigators disassembled the muffler and noted that one cone shaped baffle had separated from the end plate and was blocking the end opening of the muffler Upon shaking th
182. lider was reportedly controllable with minimal difficulty with the simulated cable failure A complete traffic pattern was flown with the simulated failed cable and rudder was only used during the final portion of the landing due to crosswinds at the airport In the wake of the accident Jonker Sailplanes issued one Service Bulletin SB JS 007 and three Technical Notes TN JS 009 TN JS 010 and TN JS 011 pertaining to the rudder control system cables and locking mechanism SB JS 007 specifies regular cable and rudder pedal mechanism inspection intervals and techniques It refers to TN JS 009 and TN JS 010 for instructions in replacing the rudder cables and pedal locking mechanism respectively Finally TN SJ 010 specifies the availability of a refined rudder pedal S tube design to reduce wear damage to the rudder cables The new pedal S tubes exhibit four wear reducing changes 1 2 3 4 Redesign of the S tube geometry to reduce the distance from the lower S tube opening to the pedal axis of rotation Flanges at both openings of the S tube No cutoff at the lower S tube opening A tubular nylon lining between the S tube and the cable ee SS a Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 60 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportati
183. llowing procedures Pacific Wings incorporates Spidertracks which provides company management personnel with a real time moving map display of the airplane s progress During an interview with the National Transportation Safety Board NTSB investigator in charge IIC on June 6 the operator s director of operations reported that after returning from a flight he was alerted that the flight track for the accident airplane had stopped transmitting along the anticipated route to LeConte Glacier Inquiring of the company flight follower and unable to establish radio contact with the pilot he initiated a search for the missing airplane He said the 45 minute tour flight had a standard route but pilots were allowed to alter that route based on weather conditions About 1547 approximately 16 minutes after the accident the United States Coast Guard USCG Alaska received a 406 Mhz emergency locator transmitter ELT signal assigned to the accident airplane At approximately 1614 after being notified of an overdue airplane and after leaming about reports of an emergency locator transmitter ELT signal along the accident pilot s anticipated flight route search and rescue personnel from the U S Coast Guard Air Station Sitka began a search for the missing airplane About 1816 the crew of a U S Coast Guard HH 60 helicopter located the airplane s wreckage in an area of mountainous tree covered terrain A rescue swimmer was lowered to the accident site and
184. lot telephoned for assistance using his mobile phone PERSONNEL INFORMATION The pilot held an airline transport pilot certificate with instrument airplane and single and multi engine land ratings He reported a total flight experience of about 3 800 hours including about 830 hours in the accident airplane make and model His most recent FAA third class medical certificate was issued in July 2008 and his most recent flight review was completed in October 2011 AIRCRAFT INFORMATION According to FAA information the airplane was manufactured in 2006 and was equipped with a Teledyne Continental Motors 10 550 series engine Pilot provided information indicated that as of its most recent annual inspection in November 2010 the airplane had accrued a total time in service of 8 131 hours The pilot estimated that the engine had accumulated about 200 hours in service since it had been overhauled The airplane was equipped with an electric fuel boost pump that was to be used for starting the engine and was normally kept off for cruise flight It was also equipped with a JPl brand fuel flow indicator and JPI engine monitor The engine monitor was extracted from the airplane and was sent to the NTSB Recorders Laboratory in Washington DC for data download The accident flight data was successfully downloaded and review of the data did not indicate any operational abnormalities Review of the data revealed that about 2 minutes and 10 seconds before the end
185. ls were equipped with a single disc hydraulic brake assembly which was actuated by individual cylinders attached to each rudder pedal or by a hand lever The hand lever also doubled as a parking brake According to FAA and maintenance records N47749 was manufactured in 1977 The airplane s most recent 100 hour inspection was completed on April 30 2012 At the time of the inspection the airplane had accrued 7 174 total hours of operation According to FAA and maintenance records N602FT was manufactured in 1989 The airplane s most recent 100 hour inspection was completed on April 30 2012 At the time of the inspection the airplane had accrued 17 077 total hours of operation METEOROLOGICAL INFORMATION The reported weather at MLB at 2127 included winds 190 degrees at 9 knots 10 miles visibility sky clear temperature 26 degrees C dew point 21 degrees C and an altimeter setting of 29 93 inches of mercury According to the United States Naval Observatory on the day of the accident sunset occurred at 2010 and the end of civil twilight occurred at 2036 The phase of the Moon was a waxing crescent with 3 percent of the Moon s visible disk illuminated Moonset was at 2145 AIRPORT INFORMATION Melbourne International Airport was a towered public use airport located 2 miles northwest from the city of Melbourne Florida Aircraft operations averaged 366 per day of which 54 percent were transient general aviation 40 percent were local genera
186. lures can cause partial or complete engine power loss by restricting the flow of the exhaust gases If pieces of the intemal baffling break loose and partially or totally block the flow of exhaust gases an engine failure can occur It is likely the exhaust gas was partially or totally blocked by the separated baffle cone during the flight which resulted in a loss of engine power Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS The separation of the end baffle cone inside the muffler which blocked airflow through the engine after takeoff and resulted in a loss of engine power and an off airport landing into obstacles Events 1 Enroute climb to cruise Loss of engine power partial 2 Enroute climb to cruise Powerplant sys comp malfffail 3 Landing Off field or emergency landing 4 Landing Collision with terr obj non CFIT Findings Cause Factor 1 Aircraft Aircraft power plant Engine exhaust Noise suppressor Damaged degraded C 2 Environmental issues Physical environment Object animal substance Tree s Effect on equipment Narrative HISTORY OF FLIGHT On July 5 2011 about 1900 Pacific daylight time a Cessna R182 N7392X collided with a tree during an off airport forced landing following a loss of engine power during climb to cruise altitude after takeoff from Hesperia Califomia The pilot owner was operating the airplane under the provisions of 14 Code of Federal Regu
187. m National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt ANC13FA054 06 04 2013 1531 AKD Regis N616W Petersburg AK Apt N a Acft Mk MdI DEHAVILLAND BEAVER DHC 2 MK 1 Acft SN 1290 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl P amp W R 985 SERIES AcftTT 34909 Fatal 1 Serlnj 2 Fit Conducted Under FAR 135 Opr Name PACIFIC WINGS LLC Opr dba Aircraft Fire NONE Narrative HISTORY OF FLIGHT On June 4 2013 about 1531 Alaska daylight time a float equipped de Havilland DHC 2 Beaver airplane N616W sustained substantial damage when it collided with mountainous tree covered terrain about 14 miles east of Petersburg Alaska The airplane was being operated by Pacific Wings LLC as a visual flight rules VFR sightseeing flight under the provisions of 14 Code of Federal Regulations Part 135 when the accident occurred Of the seven people on board the certificated airline transport pilot and three passengers sustained minor injuries two passengers sustained serious injuries and one passenger was fatally injured Visual meteorological conditions prevailed and company flight following procedures were in effect The flight originated at the Lloyd R Roundtree Seaplane Facility at the Petersburg Harbor Petersburg about 1519 The flight was a sightseeing flight for cruise ship passengers and the passengers cruise ship was docked in Petersburg As part of their company flight fo
188. meter time of 3 931 0 hours TESTS AND RESEARCH The turbocharger clamp pieces were collected and sent to the National Transportation Safety Board Material laboratory for further examination The V band exhaust clamp had a 2 segment retainer V portion of the clamp and was installed on the turbocharger exhaust gas outlet on the accident airplane The band flat outer strap was fractured near the end of the wrap for the t bolt assembly Two circumferential cracks were also observed in the retainer extending from the gap opposite from the t bolt Each retainer segment contained one circumferential crack The clamp was generally covered in oxides and sooty deposits The fracture occurred at the edge of a spot weld attaching the band to the retainer and the fracture surface was on slant planes Slant plane fracture features were observed from the edges of the spot weld out to the edges of the band and were consistent with ductile overstress fracture Reduced width of the band associated with necking deformation was observed adjacent to the fracture In addition the edges of the band were deformed radially inward Similar necking deformation with edges deformed radially inward was observed at the mirror opposite side of the band In the vicinity of the spot weld fracture occurred in part in a flat transverse plane However slant plane fracture was also observed at this location The flat plane fracture was located near the middle of the thickness and a s
189. n reported to EKU s maintenance provider at that time The drain valve was removed the small O ring at the bottom of the fuel strainer was replaced and the drain valve was reinstalled The larger O ring in the top of the bowl had been replaced the day before and the maintenance provider inspected it once again found it to be serviceable and reinstalled it When the fuel selector was tumed on no leaks were detected and the airplane was released for service No log book entry however was made indicating that this maintenance action had occurred TESTS AND RESEARCH Fuel System The airplane s fuel system consisted of two vented 28 gallon integral fuel tanks one tank in each wing a three position fuel selector valve auxiliary fuel pump fuel shutoff valve fuel strainer engine driven fuel pump fuel air control unit fuel distribution valve and fuel injection nozzles Fuel would flow by gravity from the two wing tanks to a three position selector valve labeled BOTH RIGHT and LEFT and on to the reservoir tank Then from the reservoir tank fuel flowed through the auxiliary fuel pump past the fuel shutoff valve then through the fuel strainer to the engine driven fuel pump From the engine driven fuel pump fuel was delivered to the fuel air control unit where it was metered and directed to a fuel distribution valve manifold which distributed it to each cylinder Fuel flow into each cylinder was continuous and flow rate was determined by
190. nal Transportation Safety Board Aircraft Accident Incident Database Accident Rpt ERA14CA118 02 09 2014 1500 EST Regis N103KW Sussex NJ Apt Nia Acft Mk MdI BELLANCA 7KCAB Acft SN 512 75 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING I0 320 E2A AcftTT 2500 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name AVIATION CLUB OF SUSSEX LLC Opr dba Aircraft Fire NONE AW Cert STA Narrative The pilot stated that he did not verify the quantity of fuel in the airplane s fuel tanks prior to departure About 15 minutes into the flight the engine began to sputter then experienced a total loss of power After looking at the airplane s fuel gauges the pilot determined that the airplane had run out of fuel The pilot subsequently conducted a forced landing to a snow covered field Upon touchdown the airplane nosed over and came to rest inverted resulting in substantial damage to the right wing The pilot reported there were no mechanical malfunctions or anomalies that would have precluded normal operation of the airframe or engine Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 9 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt WPR1
191. nd ibuprofen were detected in the urine specimen Additionally the following was detected in the vitreous fluid 18 1 mg dL urea nitrogen 0 55 mg dL creatinine 140 mEq L sodium 14 5 mEq L potassium 121 mEq L chloride and less than 10 mg dL glucose The carboxyhemoglobin saturation was 0 69 percent Iron 420 mcg g was detected and was above the reporting limit of 1 9 mcg g TESTS AND RESEARCH Examination of the fractured right wing pieces was performed by the NTSB Materials Laboratory located in Washington DC The results of the examination revealed the outboard portion the forward spar at the fracture area was deformed up relative to inboard portion while the outboard portion of the aft spar at the fracture area was deformed forward and slightly up relative to the inboard portion Bench binocular microscope examination of the forward and aft spar pieces for the right wing revealed the fractures faces exhibited slant fractures with coarse features consistent with overstress separation with no evidence of fatigue cracking The aft spar contained a through hole in the area above the trailing edge wing strut Examination revealed the fracture in the aft spar intersected the center portion of this hole exposing the outboard and inboard side of the hole The inboard face of the hole was severely deformed consistent with ground impact damage whereas the mating half of the hole for the most part did not show evidence of deformation damage Printed May
192. nd lever and master cylinder located below and behind the center of the instrument sub panel Hydraulic cylinders were located above each rudder pedal and adjacent to the hand brake lever A brake fluid reservoir was installed on the top left front face of the fire wall The parking brake was incorporated in the master cylinder and was actuated by pulling back on the hand lever and depressing the knob attached to the left side of the handle The parking brake was released by pulling back on the hand lever to disengage the catch mechanism and allow the handle to swing forward Review of the toe brake installation indicated that that if a pilot did not place his feet in the proper position and his toes were allowed to protrude over the toe stops on the rudder pedals that full braking may not be available as they would come into contact with the torque tube that the rudder pedal assembly was attached to Review of the parking brake installation also indicated that once the parking brake was applied that in order to obtain additional braking effort the hand lever had to be released before once again operating the toe brakes or hand lever ORGANIZATIONAL AND MANAGEMENT INFORMATION Florida Institute of Technology FIT was founded in 1958 to provide advanced education for professionals working in the space program at what is now the Kennedy Space Center They offered educational programs in numerous disciplines including aeronautics The college of
193. nd set to the left tank However it was determined that some fuel had migrated from the fuller right tank to the nearly empty left tank via the tank vent line while the airplane was inverted The pilot stated that his typical habit was to operate the airplane with the fuel selector set to the both position but that at some point during the flight he had moved the fuel selector to the left tank to correct a fuel imbalance with the intention of resetting it to the both position once the imbalance had been corrected The pilot reported that he realized that he had forgotten to reset the fuel selector to the both position and that this caused the power loss The pilot reported that he did not manipulate the fuel selector handle after the power loss because he did not believe that he had a fuel problem and that he did not refer to any emergency checklists The Pilot s Operating Handbook contained an engine failure during flight checklist which included the step to place the fuel selector valve in the both position which the pilot did not do Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS A total loss of engine power due to fuel starvation which resulted from the pilot inadvertently leaving the fuel selector set to the left tank Contributing to the accident was the pilot s deviation from his normal habit pattem and his failure to refer to the in flight engine failure checklist after the engine p
194. ndrafts that affected the airplane s flight path Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 57 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt CEN12LA265 04 29 2012 1300 Regis N555AP Clines Corner NM Apt Nia Acft Mk Mdl JONKER SAILPLANES CC JS 1B Acft SN 1B 024 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Acft TT 100 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name PALA ANGEL E Opr dba Aircraft Fire NONE AW Cert SPE Summary While in soaring flight the pilot heard a loud metallic sound come from the area near the rudder pedals and subsequently lost contact between his feet and the pedals which resulted in a temporary loss of glider control Although the pilot regained control of the glider it was descending When the glider had descended to about 10 000 feet mean sea level the pilot chose to bail out with a parachute due to the descent rate and the unfavorable terrain for landing The glider subsequently impacted a mesa and sustained substantial damage Subsequent examination of the adjustable rudder pedal system revealed that the right rudder cable had fractured at the forward opening of the S tube on the right rudder pedal Examination of t
195. ng gear emergency extension mechanism was broken and the electric drive motor gear separated The emergency locator transmitter ELT was separated from the mount fragmented and did not operate The ELT switch was in the ARM position The engine was impact damaged and was fragmented About 10 inches of the crankshaft remained secure to the propeller hub The sump was fragmented and no data plate was recovered The engine s n observed on the top front portion of the case was L 20394 40A The propeller was mostly buried in the impact crater beneath the engine with one blade exposed During wreckage retrieval the propeller was examined Propeller blade A was secure in the hub and was bent aft from the root about 20 degrees with S bending along the full length of the blade The leading edge had numerous substantial dents and gouges and the front of the blade displayed numerous chordwise scratches Blade B was secure in the hub and bent aft from the root area about 10 to 15 degrees The blade tip was separated about 10 inches from the tip and was found adjacent to the blade in the impact crater The blade displayed substantial leading edge dents and gouges as well as chordwise scratches Blade C was separated from the propeller hub at the blade root The blade was bent aft and also showed twisting toward low pitch The blade displayed leading edge dents and gouges as well as chordwise scratches A handheld GPS device an engine driven vacuum pump and two gyros
196. ng handbook The pilot reported for the return leg he again visually checked the fuel level in each tank He estimated 12 15 gallons in the left tank and 10 in the right for a total of 22 25 gallons The pilot added that fuel bum seemed normal and he decided not to add fuel he also stated that estimations are not an accurate science and that a fuel stick was not provided to confirm the fuel level After departing for the retum flight he switched fuel tanks from the left side to the right side About 15 minutes later the pilot noticed a reduction in power and switched back to the left side fuel tank Engine power was restored and the pilot stated that he did not feel that the fuel had been exhausted from the right side based on his calculations A few minutes later the engine lost power and the pilot preformed a forced landing to a construction site A post crash examination of the airplane revealed substantial damage to the airplane s fuselage and left wing during the forced landing Additionally the Federal Aviation Administration inspector reported that the fuel tanks were empty and were not breached in the accident Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 68 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident
197. nical failures or malfunctions of the airplane or engine that would have precluded normal operation and that the airplane was substantially damaged The right wing outboard of the right fuel tank was crumpled back and the leading edge was torn away The right aileron was tom at the hinge point the right inboard flap was jammed into the fuselage above the rear window the window was broken and the top of the fuselage was crumpled The right horizontal stabilizer was bent and the right elevator trim tab was bent down The left horizontal stabilizer was bent and the left elevator was bent downward The right door was also jammed shut and the right window had popped open and was unable to be closed Both fuel tank caps were closed The fuel tanks were devoid of fuel and neither was breached There also was no fresh fuel staining above or below the wings or on the belly of the airplane With electrical power both off and selected on the fuel quantity indicator read 0 for both fuel tanks The fuel selector was in BOTH and the fuel shut off valve was open Fuel was present in the fuel strainer but no fuel was found in the fuel line from the fuel strainer to the engine driven pump Engine Run Both magnetos produced spark and 7 quarts of oil was present in the engine After adding 5 gallons of 100LL aviation gasoline to the left wing tank the electric fuel pump was turned on and the engine was started Starting was normal and the engine was accele
198. ns Part 91 Visual meteorological conditions prevailed for the personal cross country flight which had originated from Dalhart Texas about 3 hours before the accident A flight plan had not been filed The pilot said that he started his traffic pattern higher than recommended due to his high density altitude concems He said his final approach was longer than normal and his speed was fast He put the flaps down full and raised the nose to bleed off more airspeed A witness on the ground said the airplane passed the midfield intersection and was still quite high off the runway The witness said the accident pilot appeared to be performing a go around But then the airplane descended to the runway and touched down with about 3 4 of its length behind him The pilot said that he realized that the airplane was high fast and long for a normal landing He decided to go around He applied full power he reduced flaps by 10 degrees and the airplane started to climb However the airplane then began to descend it was sort of mushing out of the sky He reduced the engine power landed and began heavy braking A witness on the ground said that he observed black smoke coming from the main landing gear tires after the airplane touched down The airplane departed the end of the runway and went through the airport s perimeter fence The airplane came to rest on its nose with the right wing strut bent and both wings bent and wrinkled After he exited the airplane the
199. ns to the McCauley party coordinator regarding test and examination following receipt of the McCauley Teardown Inspection Report dated March 3 2014 The report stated that recovery personnel indicated that rain likely entered the propeller during its storage in a truck bed with the propeller mount flange uncovered Four of the six propeller governor cap screws were missing and the remaining two screws were finger tight In response to the question of whether the propeller blades actuating piston were sticking the party representative stated that shimming was in place on each propeller blade which was shimmed properly and could be rotated freely and smoothly When asked the condition of the piston seal the representative stated that the seal was undamaged and engine oil in the cylinder dome and the red oil in the propeller were not intermixed When asked if a compression test was performed of the propeller dome the representative stated that all the actuation links were broken in tension during the propeller strike and a pressure check of the cylinder dome would not have rotated the blades a pressure check was not performed When asked what the low and high pitch stop settings were the representative stated that the pitch stops were set with shim washers on the propeller which were in place The angle verification of the stops was not performed due to breakage of all the actuation links that connect the piston to the blades the stack heights did not appea
200. nspection Examination of the operator s fueling pad and parking ramp revealed that they were significantly sloped Examination of its fueling and parking procedures also revealed that the airplanes were being parked and serviced with the fuel selector valves in the both position According to the airplane manufacturer the airplane should be parked in a wings level normal ground attitude with the fuel selector in the left or right position to ensure maximum fuel capacity and minimize cross feeding when refueling sf Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS A total loss of engine power due to fuel exhaustion Contributing to the accident was the flight instructor s failure to supervise the student s preflight inspection his inadequate fuel management and preflight and in flight fuel planning and the operator s inadequate fueling policies and procedures Events Prior to flight Preflight or dispatch event Enroute cruise Fuel exhaustion Enroute cruise Loss of engine power total Emergency descent Off field or emergency landing Landing landing roll Collision with terr obj non CFIT Si BD Findings Cause Factor 1 Aircraft Fluids misc hardware Fluids Fuel Fluid management C 2 Personnel issues Action decision Info processing decision Decision making judgment Instructor check pilot C 3 Aircraft Fluids misc hardware Fluids Fuel Fluid level C 4 Organiz
201. nything and couldn t confirm that it had gone down The witness reported that about an hour and a half later while riding on the Barrel Roll Trail he came upon the airplane wreckage and reported it to local authorities On the morning following the accident the NTSB IIC accompanied by representatives from the Federal Aviation Administration Lycoming Engines and Cessna Aircraft were assisted in accessing the accident site by local law enforcement personnel and search and rescue SAR volunteers An examination of the accident site revealed that the airplane had come to rest on the side of a mountain in an upright position oriented facing down slope on an incline of about 27 degrees The airplane s at rest magnetic heading was 350 degrees a relative impact heading could not be definitively determined A survey of the accident site revealed that both wings had remained attached to the fuselage at all attach points and that their respective flaps and ailerons had also remained attached to the respective trailing edge of the wings The fuselage aft of the cockpit cabin area was intact but almost entirely severed from the empennagertail section The rudder vertical stabilizer left and right horizontal stabilizers and both elevators sustained moderate impact damage The underside of the cockpit cabin area sustained significant deformation due to severe impact damage with the rock laden terrain A survey of the airplane revealed that all components necessary
202. o land in a pasture to check on livestock and the pilot in the front seat was on the controls They agreed on a suitable landing area and during the approach the instructor s forward visibility was limited and he failed to see that they were carrying excess airspeed and had progressed too far down the airstrip for a normal landing The front seat pilot seeing the end of the airstrip approaching rapidly applied the brakes sharply The instructor directed the pilot to relax and allow the tail to settle The brakes abruptly grabbed a second time and the tail came up sharply causing the propeller to strike the ground The airplane slid on its nose veered left and flipped onto its back The airplane sustained substantial damage to the fuselage and both wings The pilot reported no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 66 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt WPR14LA061 12 05 2013 1500 PST Regis N6595P Fair Oaks CA Apt N a Acft Mk Mdl PIPER PA 24 250 250 Acft SN 24 1717 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMI
203. ob Caus Pending Eng Mk Mdl JACOBS R 755A2M Acft TT 45 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name BENEFIT AVIATION LLC Opr dba Aircraft Fire NONE Summary The pilot reported that during the landing roll in the tailwheel equipped airplane as the rudder lost effectiveness the airplane veered to the right and then ground looped off of the runway Subsequently the left wing struck the ground which resulted in substantial damage The pilot reported that he thought he may have inadvertently applied minor application of the right brake due to his foot placement The pilot reported no mechanical malfunctions or failures with the airplane that would have precluded normal operation Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS The pilot s failure to maintain directional control of the airplane during landing Events 1 Landing landing roll Loss of control on ground Findings Cause Factor 1 Personnel issues Task performance Use of equip info Aircraft control Pilot C 2 Aircraft Aircraft oper perf capability Performance control parameters Directional control Not attained maintained C Narrative The pilot reported that during the landing roll in the tailwheel equipped airplane as the rudder lost effectiveness the airplane veered to the right and then ground looped off of the runway Subsequently the left wing struck the ground which resulted in substantial damage
204. of the airframe logbooks and engine logbooks showed an entry dated July 4 2011 which certified that an annual inspection had been completed at 4 800 1 total aircraft hours The most recent airframe logbook entry was made on December 15 2011 at an aircraft total time of 4854 4 hours when engine s n L 20394 40A was installed on the accident airplane At that time the engine had accumulated 2794 8 hours with 636 8 hours since its most recent overhaul Engine logbook entries showed that engine s n L 20394 40A had previously been installed on N33033 a Piper PA 32 260 airplane until N33033 was damaged Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 72 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database by a hurricane about October 19 2005 The damaged airplane was later sold as scrap Maintenance records for N33033 showed that an overhauled vacuum pump Airborne part number 211CC s n 1706 which was overhauled on December 16 1999 was installed on engine serial number L 20394 40A on January 21 2000 There were no other airframe logbook entries or engine logbook entries for N33033 which mentioned a vacuum pump Based on a review of the maintenance records for N33033 and the engine logbook entries
205. on Safety Board Aircraft Accident Incident Database Accident Rpt WPR14FA188 05 06 2014 1200 Regis N6704U Cody WY Apt Yellowstone Rgnil COD Acft Mk Mdl MOONEY M20C Acft SN 2436 Acft Dmg SUBSTANTIAL Rpt Status Prelim Prob Caus Pending Eng Mk Mdl LYCOMING 0 360 SERIES Fatal 2 Serlnj 0 Fit Conducted Under FAR 091 Opr Name ZIMMERMAN ROBERT LEE Opr dba Aircraft Fire NONE Narrative On May 6 2014 about 1200 mountain daylight time a Mooney M20C N6704U collided with mountainous terrain near Cody Wyoming The airplane was registered to and operated by the owner under the provisions of 14 Code of Federal Regulations Part 91 The private pilot owner and private pilot rated passenger were presumed to have sustained fatal injuries The airplane sustained substantial damage to the forward fuselage and both wings The cross country personal flight departed Yellowstone Regional Airport Cody about 1140 with a presumed destination of Twin Falls Idaho Instrument meteorological conditions prevailed at the accident site and no flight plan had been filed Both occupants were brothers and had departed from Fayetteville North Carolina on April 28 in the accident airplane with the intention of touring the country to visit friends and relatives Their ultimate destination was the Seattle area where they had planned on arriving by May 11 Family members became concerned when they had not heard from both occupants by May 8 and initiated a ser
206. ontributed to outcome C Personnel issues Task performance Planning preparation Flight planning navigation Instructor check pilot C SIPs Os Narrative On August 20 2012 about 1115 mountain daylight time a Cessna 182Q N735KV sustained substantial damage when it impacted trees and terrain during climb in rising mountainous terrain near McCall Idaho The flight instructor and his commercial pilot rated student both received minor injuries The owner pilot was operating the airplane under the provisions of 14 Code of Federal Regulations Part 91 Visual meteorological conditions prevailed for the instructional cross country flight which had originated from Mackay Bar Airport Dixie Idaho about 15 minutes before the accident The flight instructor said the intended destination was McCall a flight plan had not been filed The flight instructor said they departed Mackay Bar Airport elevation 2 172 feet and flew down the Salmon River while gaining speed and altitude At Warren Creek they turned south while still climbing They came to a Y in the canyon and he directed the pilot receiving instruction to take the right branch Soon thereafter the increase in terrain elevation exceeded the airplane s climb performance The airplane impacted trees and struck the ground The elevation of the accident site was about 6 593 feet The nearest weather reporting station reported the temperature was 65 degrees Fahrenheit and 30 15 inches of mercury pressure wh
207. or flight control cable s tumbuckle assembly had broken at the aft cable terminal fitting Examination of the turnbuckle and aft cable terminal fitting by the NTSB Materials Laboratory revealed that the cable terminal had fractured in the shank region about 0 25 inches from the wrench flats Areas of the tumbuckle were covered with a white crystalline material and the shank adjacent to the fracture exhibited reddish orange deposits Examination of the fractured region with a 5X to 50X binocular zoom stereomicroscope also revealed that the fracture surface was rough with crack branching which was consistent with stress corrosion cracking Cleaning of the terminal in the area of the wrench flats and adjacent shank areas using acetone and a scouring pad comparable to a Scotch Brite general purpose green scouring pad also revealed that some of the reddish orange deposits remained in some of the crevices on and adjacent to the wrench flats Isolated areas of small pits were also observed on the tumbuckle shanks with a higher density of pits being observed on the outer diameter at the wrench flats Additionally a longitudinal crack was discovered at the end of the terminal adjacent to the cable The area around the crack was also cleaned using acetone and a paper towel and reddish orange deposits remained adhered to the surface after cleaning Review of Federal Aviation Administration FAA records revealed that the turnbuckle assembly was the subject of FAA Airwort
208. ore the final resting place of the main wreckage Fire consumed the majority of the airframe skin and structure Investigators identified remnants of all flight controls and airframe structure MEDICAL AND PATHOLOGICAL INFORMATION A postmortem examination was conducted by the Kern County Coroner the cause of death was multiple blunt force injuries The FAA Forensic Toxicology Research Team Oklahoma City Oklahoma performed toxicological testing of specimens of the pilot The analysis contained no finding for ethanol in urine they did not perform tests for carbon monoxide or cyanide The report contained the following findings for tested drugs Tamsulosin detected in Liver Terazosin detected in urine and Terazosin detected in Liver TESTS AND RESEARCH Investigators from the NTSB FAA Cessna and Continental Motors Inc CMI examined the wreckage at Aircraft Recovery Service Littlerock Califomia on September 7 2011 A detailed report is part of the public docket for this accident A postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation The elevator trim actuator was extended 1 7 inches which equated to 5 degrees tab up The elevator trim cable was continuous from the tail to the chain in the cabin The flap actuator measured 4 7 inches which indicated that 4 4 inches is the retracted position Printed May 22 2014 an airsafety com
209. orted that while in cruise flight at 5 000 feet mean sea level approximately five nautical miles from Homerville Airport HOE Homerville Georgia there was a sudden loss of power in the left engine The pilot reported no indication of a loss in oil pressure or increased engine temperature prior to the loss of power The pilot feathered the left propeller and began a descent into HOE Although the left propeller was feathered the airplane could not maintain altitude The pilot realized he would not be able to make it to HOE and decided to make a forced landing on a road During the landing roll out the airplane veered off the road into a ditch Examination of the airplane by a Federal Aviation Administration inspector on scene confirmed structural damage to the fuselage wings and empennage The airplane was defueled and no debris was found within the fuel prior to the aircraft recovery During the examination of the left engine a test run was conducted It was noted that the engine would only run when the airframe electric fuel boost pump was in the on position When the boost pump was turned off the engine would stop running The engine driven fuel pump was removed and examined The drive coupling was intact and not damaged and the fuel pump drive shaft rotated freely The engine driven fuel pump was removed and sent to Continental Motors Incorporated CMI Analytical Department for examination The engine driven fuel pump was flow tested and disassemble
210. orthern Califomia Terminal Radar Approach Control NORCAL who told him he had struck a helicopter He maintained straight and level flight by utilizing continuous left aileron and rudder control inputs During the final approach segment the propeller speed began to decrease and he was unable to maintain altitude As the airplane began to slow down it began to pitch to the right despite his left control inputs The airplane subsequently landed hard in a field short of the runway The helicopter pilot stated that she departed Hayward with a route that was to follow highways to Concord Antioch and ultimately Sacramento She contacted NORCAL Approach for flight following once she had reached Dublin and was issued a discreet transponder code Once over Concord the approach controller transferred her to Travis Air Force Base Radar Approach Control She continued the flight and stated that a short time later she received a traffic advisory from the Travis controller She turned on the helicopter s landing lights to increase her visibility and began looking for the traffic she further reported that she may have tumed off the light a short time later She stated that based on her communication with air traffic controllers she did not perceive the situation to be urgent She thought she received two traffic advisories in total The flight continued and she initiated a left turn to the north while relaying this information to the controller A short time later
211. ower loss Events 1 Enroute descent Loss of engine power total 2 Enroute descent Off field or emergency landing Findings Cause Factor Aircraft Fluids misc hardware Fluids Fuel Incorrect use operation C Personnel issues Task performance Use of equip info Use of equip system Pilot C Personnel issues Task performance Use of equip info Use of checklist Pilot F Personnel issues Task performance Use of equip info Use of policy procedure Pilot F Aircraft Fluids misc hardware Fluids Fuel Fluid level C Se ONS Narrative HISTORY OF FLIGHT On October 28 2011 about 1350 Pacific daylight time a Cessna 185 N520YH was substantially damaged during an off airport forced landing near Prineville Oregon following a complete loss of engine power The owner pilot and the two passengers were not injured The personal flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91 Visual meteorological conditions prevailed and no flight plan was filed for the flight According to the pilot the flight originated from a private airstrip in central Idaho and was destined for Bend Municipal Airport BDN Bend Oregon The pilot estimated that the departure fuel quantity was 57 gallons The cruise portion of the flight was conducted at an altitude of 10 500 feet in accordance with visual flight rules without air traffic control services About 2 5 hours after takeoff the pilot began a cruise descent for BDN by
212. pattem on a 45 degree angle or on the downwind leg of the traffic pattern Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 24 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt CEN14LA217 04 25 2014 1330 CDT Regis N9373F Llano TX Apt Llano Muni AQO Acft Mk Mdl CESSNA 172R Acft SN 17280160 Acft Dmg SUBSTANTIAL Rpt Status Prelim Prob Caus Pending Eng Mk Mdl LYCOMING 10 360 Fatal 0 Serin 0 Fit Conducted Under FAR 091 Opr Name GENESIS FLIGHT ACADEMY Opr dba Aircraft Fire NONE AW Cert STN Narrative On April 25 2014 about 1330 central daylight time a Cessna 172R airplane N9373F collided with trees following a loss of engine power while departing the Llano Municipal Airport KAQO Llano Texas The private pilot and two passengers were not injured The airplane was substantially damaged The airplane was registered to Dirty Side Down Aviation LLC and operated by Genesis Flight Academy under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight Visual meteorological conditions prevailed for the flight which operated without a flight plan The flight was originating at the time of the accident According to a statement provided by the pilot the
213. pection also installed the carburetor and then removed it for the post accident examination The airplane owner stated that during the post accident removal of the carburetor there were no mechanical anomalies with the carburetor heat system The pilot stated that there was an engine rpm decrease when he checked the operation of carburetor heat during an engine run up prior to departing on the accident flight The MLI Automated Surface Observing System ASOS recorded the following observation At 1715 special unscheduled report wind 340 degrees at 11 knots gust 21 knots visibility 1 statute mile runway 9 runway visual range 6 000 feet weather phenomena light frozen precipitation sky condition broken at 2 700 feet mean sea level broken at 4 000 feet overcast at 4 900 feet temperature 1 degree Celsius dew point 5 degrees Celsius altimeter 29 55 inches of mercury The pilot stated that the airplane did not enter any of the snow showers that were approaching MLI during the accident flight He said that the snow showers arrived at MLI about 30 minutes after the accident Special Airworthiness Bulletin CE 09 35 Carburetor Icing Prevention includes a graph that shows the probability of carburetor icing for various temperature and relative humidity conditions At a temperature and dew point as recorded by the MLI ASOS there was a probability of icing in glide and cruise power The received carburetor was a Marvel Schebler M
214. plane began to slow down it began to pitch to the right despite his left control inputs The airplane subsequently landed hard in a field short of the runway The helicopter pilot stated that she departed Hayward with a route that was to follow highways to Concord Antioch and ultimately Sacramento She contacted NORCAL Approach for flight following once she had reached Dublin and was issued a discreet transponder code Once over Concord the approach controller transferred her to Travis Air Force Base Radar Approach Control She continued the flight and stated that a short time later she received a traffic advisory from the Travis controller She turned on the helicopter s landing lights to increase her visibility and began looking for the traffic she further reported that she may have tumed off the light a short time later She stated that based on her communication with air traffic controllers she did not perceive the situation to be urgent She thought she received two traffic advisories in total The flight continued and she initiated a left turn to the north while relaying this information to the controller A short time later she caught site of the silhouette of an airplane and propeller at her 4 o clock position She performed an evasive maneuver to the left and then felt the helicopter being struck She did not know the extent of the damage and elected to immediately perform a precautionary landing The area below was unlit and dark and she w
215. ported that to accommodate the engine run a cylinder head temperature probe was installed at the 2 cylinder position The oil pressure fitting to the oil pressure gauge was also replaced as the original fitting was damaged as a result of the accident The engine was then installed on an engine test stand with a test club propeller installed The inspector reported that the engine started with no hesitation or stumbling The inspector further reported that during the magneto drop test at 1 800 rpm the right magneto serial number E06DA051 was observed to create stumbling symptoms produced by the engine with a drop between 400 to 425 rpm The left magneto serial number E08GA072R dropped about 90 rpm when the engine was run up at 1 800 rpm There was no hesitation or stumbling observed from the engine The engine was then shut down No other anomalies with either the airframe or engine were reported by the inspector that would have precluded normal operation Under the supervision of the NTSB IIC a subsequent examination of the right magneto serial number EQ6DA051 was performed at the facilities of Aircraft Magneto Service Bainbridge Island Washington on August 15 2013 The technician reported that although he observed minimal oil in the magneto housing this would not have resulted in operational difficulties of the magneto He then assembled the magneto from the parts provided and noted that the breaker point opening and internal timing was untou
216. power During the forced landing to a paved road the right wing tip struck a pole and was substantially damaged Fuel was found onboard the airplane A postaccident examination of the airplane and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS A loss of engine power during climb for reasons that could not be determined because postaccident examination did not reveal any anomalies that would have precluded normal operation Events 1 Enroute climb to cruise Loss of engine power total 2 Emergency descent Off field or emergency landing 3 Landing Collision with terr obj non CFIT Findings Cause Factor 1 Not determined Not determined general general Unknown Not determined C 2 Aircraft Aircraft power plant Engine reciprocating general Not specified 3 Environmental issues Physical environment Object animal substance Pole Contributed to outcome Narrative On August 31 2012 about 1050 Pacific daylight time a Mooney M20J N132PC sustained substantial damage during a forced landing following a loss of engine power near Chelan Washington The commercial pilot the sole occupant sustained minor injuries The pilot owner was operating the airplane under the provisions of 14 Code of Federal Regulations Part 91 Visual meteorological conditions prevailed for the
217. pt the pilot stated that the approach was too fast and too high so he performed a go around On the accident landing the airplane landed farther down the 2 610 foot runway than he anticipated The airplane did not slow down and as the end of the runway approached the pilot applied the brakes The airplane subsequently veered to the left and right and then back to the left again which allowed the right wing to contact the runway The nose of the airplane impacted a snow berm and the airplane came to rest inverted which resulted in substantial damage to the wing and fuselage An examination of the airplane revealed no mechanical malfunction or failure that would have precluded normal operation Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 14 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt CEN14LA134 01 26 2014 1717 CST Regis N4VN Milan IL Apt Quad City International Airpor MLI Acft Mk Mdl CESSNA 172K Acft SN 17258242 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING 0 360 A1A L 14253 36A AcftTT 4574 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name PILOT Opr dba Aircraft Fire NONE Narrative On January 26 2014 at 1717 centr
218. r unusual The representative also stated that the top cover of the governor had been removed therefore control arm clocking travel could not be verified The engine was overhauled at a repair facility following the airplane s recovery Maintenance personnel from the facility stated that the engine underwent a pressure differential test across the front nose bearing per Lycoming Service Instruction 1462A At a delivery pressure of 35 psi the indicated pressure was 18 psi the limits was 6 to 35 psi There was no obstruction in the front main bearing for oil delivery The fuel pump and fuel servo Bendix RSA 5AD1 part number 2576544 3 serial number 70A72401 were tested and noted to be within test limits The mechanic from the overhaul facility stated that engine oil travel travels down the left hand case half that eventually feeds the propeller govemor The propeller governor receives the oil and amplifies the pressure and then transfers the oil through a passage down to the center of the front main bearing It then travels through the cavity in the front bearing to where it passes through the transfer tube in the crankshaft exits the propeller hub He said that it was a closed system from the govemor to the propeller hub Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 32 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 69
219. race would have been removed from service in July 2012 Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS Company maintenance personne s failure to comply with the airplane manufacturer s service instructions by not removing the cracked drag brace from service nor inspecting the repaired drag brace at the appropriate interval which resulted in the failure of the nose landing gear drag brace due to fatigue cracking and collapse of the nose landing gear during the landing roll Contributing to the failure of the nose landing gear drag brace was the failure of the repair station to detect a remaining portion of a crack following repair Events 1 Landing landing roll Sys Comp malfffail non power 2 Landing landing roll Landing gear collapse Findings Cause Factor Aircraft Aircraft systems Landing gear system Nose tail landing gear F atigue wear corrosion C Aircraft Aircraft systems Landing gear system Nose tail landing gear Incorrect service maintenance C Personnel issues Task performance Inspection Post maintenance inspection Maintenance personnel C Personnel issues Task performance Inspection Scheduled routine inspection Maintenance personnel C Organizational issues Management Scheduling Maintenance scheduling Operator C Sr AS Narrative On August 31 2012 about 1630 eastern daylight time a Cessna 402C N769EA registered to and operated by Hyannis Air Service Inc dba
220. racked by the operator they were asked by NTSB to determine the actual number of cycles since installation of the nose landing gear drag brace they reported it was 286 The operator also reported that the nose landing gear drag brace total time since June 2011 was approximately 1 134 hours At the time of the incident the operator was removing the nose landing gear drag brace every 400 hours to comply with Cessna Multi Engine Service Bulletin MEB91 11R1 Cessna Multi Engine Service Bulletin MEB91 11 Revision 1 dated February 24 2003 indicates reports of cracking of the nose landing gear drag brace near the actuator attach lugs which could result in a drag brace failure and inability of the nose landing gear to lock in the down position The bulletin indicates that airplanes that have a nose landing gear drag brace that was shipped from Cessna Parts distribution on or after July 2 2002 are exempt from the bulletin Additionally the bulletin indicates that for airplanes with the P N of drag brace installed 5142002 5 shall be inspected within the next 250 landings or 12 Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 38 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database months whichever occurs
221. rated up to 1 800 rpm before the airplane began to slide on the long grass of the field A magneto check was then performed and both magnetos dropped approximately 100 rpm The fuel selector was then switched between the LEFT and BOTH During the engine run no fuel leakage was observed Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 20 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Re Examination On April 20 2012 the airplane was moved to 139 where fuel staining was observed on the lower fuselage just aft of the firewall by EKU personnel As a result on April 25 2012 a reexamination was conducted During the reexamination the fuel strainer was reexamined and no leakage or anomalies were noted The floor and wings were also opened up and no evidence of leakage or staining was discovered Examination of the fuel stains revealed that it was light in color indicating that it had been exposed to the elements and had been present for a considerable period of time Review of the airplane s discrepancy log also indicated that the staining may have occurred prior to March 21 2012 when a fuel leak was discovered coming from the small drain valve on the bottom of the fuel strainer The leak had bee
222. reducing power to 20 inches of manifold pressure and adjusting mixture as required to keep the engine temperature values within the desired ranges When the airplane was approximately 10 miles from BDN and descending through about 6 500 feet the engine suddenly ceased developing power At the time of the engine power loss the electronic fuel flow instrument indicated that there was sufficient fuel for about one more hour of flight In response to the power loss the pilot manipulated the throttle mixture and propeller controls but the engine did not resume developing power The pilot did Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 33 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database not manipulate the fuel selector handle or activate the fuel boost pump The pilot decided that he was committed to a forced landing off airport and selected an unpaved road in a wildemess area for the landing The landing was uneventful until the airplane was nearly stopped During the rollout at a speed that the pilot estimated to be 10 mph the airplane struck some vegetation and it nosed over onto its back The pilot shut down the airplane and he and the two passengers exited through the pilot s door The pi
223. revailed at the time of the accident and the airplane was operating on a company VFR flight plan The flight had departed Bethel about 1718 en route to Kalskag Alaska During a telephone conversation with the National Transportation Safety Board NTSB investigator in charge on March 6 the director of operations for Yute Air Alaska reported that the flight originally departed Bethel destined for Kalskag The pilot reported that about 15 minutes after departure the engine made a very loud and unusual whining noise which was followed by a partial loss of engine power He reported the problem to his dispatcher via the company radio frequency and began a tum toward a frozen pond for an emergency landing During the turn all engine power was lost He then selected a closer area of snow covered terrain with small trees as a forced landing site Just prior to touchdown the left stabilizer struck the tops of the trees resulting in substantial damage to the horizontal stabilizer After touchdown the nose tire and fork broke free of the airplane The airplane was equipped with a Continental Motors 10 520 series engine A preliminary examination of the engine by company maintenance personnel revealed a crack in the crankcase The airplane was recovered to a company facility where the engine was removed and shipped to Alaska Aircraft Engines Anchorage for further examination The engine was subsequently crated and shipped to Continental Motors Inc Analy
224. rient lost Pilot C 3 Environmental issues Physical environment Runway land takeoff taxi surface Soft Contributed to outcome Narrative On July 8 2011 about 1315 Pacific daylight time a Piper PA 22 108 N4901Z nosed over during an off airport precautionary landing near Frazier Park California The pilot owner was operating the airplane under the provisions of 14 Code of Federal Regulations CFR Part 91 The private pilot and one passenger were not injured the airplane sustained substantial damage from impact forces The personal cross country flight departed Los Banos Califomia about 1030 with a planned destination of Lompoc California Visual meteorological conditions prevailed and no flight plan had been filed The pilot stated that he had been following Interstate 5 and then turned to the west to intercept Highway 166 to Santa Maria California He thought that the airplane was losing lift and decided to land in a dry river bottom During the landing roll the nose wheel dug into soft dirt and the airplane nosed over In a subsequent statement the pilot stated that he was flying about 1 000 feet above the mountainous terrain He thought that the engine was running fine but not producing the power needed for the airplane to maintain altitude He concentrated on the terrain rather than direction The mixture was in the full rich position he did not lean it and did not recall using carburetor heat He decided to make an off airport lan
225. s 2 Taxiing or surface operations including runups 3 Takeoffs and landings including normal and crosswind 4 Straight and level flight and turns in both directions 5 Climbs and climbing turns 6 Airport traffic patterns including entry and departure procedures 7 Collision avoidance windshear avoidance and wake turbulence avoidance 8 Descents with and without turns using high and low drag configurations 9 Flight at various airspeeds from cruise to slow flight 10 Stall entries from various flight attitudes and power combinations with recovery initiated at the first indication of a stall and recovery from a full stall 11 Emergency procedures and equipment malfunctions 12 Ground reference maneuvers 13 Approaches to a landing area with simulated engine malfunctions 14 Slips to a landing 15 Go arounds According to the FAA inspector the student pilot was not certificated because she had only applied received a medical certificate and a student pilot certificate was not issued The flight endorsed the back of the student pilot s medical certificate for the solo flight According to the FAA inspector the flight instructor renewed his flight instructor certificate after he attended a 2 day flight instructor refresher clinic in February 2013 The flight instructor s pilot logbook revealed no entries showing compliance with Part 61 57 Recent Flight Experience Pilot in command for three take off landings in the previous 90
226. s a SDR it is required to submit a copy to the certificate holder Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 39 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt WPR14CA073 12 22 2013 1145PST Regis N185CY Carson City NV Apt Carson Airport CXP Acft Mk Mdl CESSNA A185F F Acft SN 18502839 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Fatal 0 Serin 0 Fit Conducted Under FAR 091 Opr Name NYE WILLIAM J Opr dba Aircraft Fire NONE AW Cert NON Summary The pilot reported that after an approximate one hour flight he returned back to the departure airport which is where the airplane was based He configured the airplane for a three point landing and touched down about 300 feet after the runway threshold Upon touchdown the airplane immediately began to veer to the right The airplane continued off the runway surface and nosed over coming to rest inverted During the accident sequence the vertical stabilizer and rudder were substantially damaged The pilot reported no pre impact mechanical malfunctions or failures that would have precluded normal operation Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRE
227. structor earlier that day before departing 139 for 75KY he watched his student perform the preflight on airplane and watched his student dip the fuel tanks with a fuel stick to visually check the fuel level in the fuel tanks Upon getting in the airplane for their one hour long training flight he asked the student how much fuel was in each tank His student advised him that they had 21 5 gallons of fuel in one tank and 20 gallons in the other Once the airplane was started the flight instructor then verified the fuel level by looking at the fuel gauges Both tanks were registering 20 gallons on the fuel gauges prior to departure After departing 139 they flew to 75KY which was located approximately 20 miles northeast of 139 to conduct a short field and soft field training lesson on the grass runway which was located there After 30 or 45 minutes of training they departed 75KY for 139 On the way back to 139 the flight instructor noticed that the fuel gauges were reading low They continued however on a direct course to 139 When they were approximately 5 miles to the north of 139 the engine started to sputter and the flight instructor took over control of the airplane He then tumed on the fuel pump and richened the mixture and the engine started running normally again At this point he decided to climb and get as much altitude as possible while maintaining a direct course for 139 Approximately 1 minute later while climbing through 3 500 feet
228. study was concluded after two cycles of one minute each followed by one cycle of three minutes a total of five minutes and it was believed that further cycling would have completely severed the right rudder cable During the three minute cycle an increasing lateral movement of the rudder pedals on the rudder pedal shaft was noted Observation revealed the right side securing nut on the shaft had backed off allowing the rudder pedal to slide laterally on the pivot tube The owner of N60VR provided documentation of the testing performed including photographs taken during the testing The glider manufacturer conducted flight testing to evaluate the flight characteristics of the glider with a simulated break of the right rudder cable The method employed to simulate the break was to remove the rudder pedal retum spring on the right rudder pedal of an exemplar glider which would allow the rudder to deflect fully to the left if the pilot removed foot pressure from both pedals If necessary the test pilot could regain full rudder control at any time by re applying foot pressure to the rudder pedals The testing included side slip and spin evaluations The spin testing confirmed that the glider could be placed into spin in either direction and recovery accomplished using only control stick movements while the rudder was fully deflected due to the simulated cable break The exemplar glider was subsequently flown from the testing area to an airport for landing The g
229. t Although the flight instructor noticed that the fuel gauges were reading low he chose to continue the flight Five miles north of the airport the engine began sputtering and the flight instructor took control of the airplane He tumed on the fuel pump and richened the fuel mixture and the engine started running normally He then decided to climb to get as much altitude as possible while continuing to fly to the airport One minute later the engine lost power The flight instructor then unsuccessfully attempted to restart the engine When he realized that the airplane would not make the runway he decided to land in a field During the approach and landing roll the airplane struck power lines and the right wing struck a tree and was substantially damaged Examination of the fuel tanks revealed that they were empty and that neither of them was breached No evidence of fresh fuel staining or leakage was found above or below the wings or on the belly of the airplane After adding 5 gallons of fuel to the left wing tank the engine was started and it ran normally Examination of the fuel sticks used by the operator revealed that they did not have aircraft registration markings on them to verify if the correct fuel stick was onboard the correct aircraft and that one of the airplanes in the fleet with 20 gallon tanks had a 26 5 gallon fuel stick in the cockpit It could not be determined whether the student pilot used the proper fuel stick during the preflight i
230. t WPR14CA138 03 15 2014 1100 PDT Regis N624RM Wrightwood CA Apt Crystal 46CN Acft Mk Mdl DG FLUGZEUGBAU GMBH DG 1000S NO Acft SN 10 129S82 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending AcftTT 1680 Fatal 0 Serin 0 Fit Conducted Under FAR 091 Opr Name SOUTHERN CALIFORNIA SOARING Opr dba Aircraft Fire NONE ACADEMY INC Narrative The pilot stated that the purpose of the flight was for him to take his cousin the sole passenger around the local ski area After departure the glider was towed to about 9 000 feet mean sea level msl and adjacent to the ski area The pilot maneuvered the glider in a 300 degree turn to the right and realized that he was at a lower altitude than the ridge He continued toward the ridge in an effort to gain lift off of the canyons As the glider continued to lose altitude it descended below 6 000 feet msl and the pilot began to look for terrain that would be favorable for an off airport landing After deciding on a location the pilot deployed the airbrakes and with the glider about 10 to 15 feet above ground level agl he intentionally stalled The glider mushed into the ground with little horizontal speed During the accident sequence the glider incurred substantial damage to the tail boom and wings The pilot reported no pre impact mechanical malfunctions or failures with the glider that would have precluded normal operation Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Dat
231. t Incident Database Accident Rpt ANC14CA017 03 02 2014 1415 AST Regis N2542K Alegnagik AK Apt Nia Acft Mk Mdl SILVAIRE LUSCOMBE 8E Acft SN 5269 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl CONTINENTAL C85 AcftTT 4236 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name NELSON RUSSELL STUART Opr dba Aircraft Fire NONE Narrative The pilot reported that he had just landed his tail wheel equipped airplane on a frozen lake During the taxi to his cabin both of the airplane s main landing gear wheels broke through overflow ice and the airplane nosed over sustaining substantial damage to the fuselage The pilot reported that there were no preaccident mechanical anomalies with the airplane that would have precluded normal operation and that the accident could have been prevented had he called a local lodge owner to check the conditions of the ice before landing Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 103 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt WPR14CA103 01 25 2014 1401 PST Regis N188L Renton WA Apt Renton Muni RNT Acft Mk MdI WACO CLASSIC AIRCRAFT YMF F5C Acft SN F5C 8 136 Acft Dmg SUBSTANTIAL Rpt Status Factual Pr
232. t plan He contacted Portland Approach Control for VFR flight following Approach Control instructed him to remain clear of the class C airspace until they had positive radar identification The pilot reversed his course and the airplane was back abeam Grove Field He remained on an easterly heading and climbed to 2 400 feet He observed rising terrain to the east He decided to head back to the west and maintained a reduced power setting and 100 miles per hour mph airspeed Portland Approach contacted the pilot and stated that they had radar contact and queried when he could accept a clearance to continue on course He replied that he could proceed on course immediately and indicated that his position was about 4 miles from the Gymme intersection which was the first waypoint on his planned route of flight He requested to cruise at 9 500 feet mean sea level msl He added full power and began a climbing left tum to proceed on course The pilot stated that he did not lose adequate terrain clearance at any time during the course reversal The airplane was at full power climbing about 400 500 feet per minute About 3 000 feet msl he felt a small bump and noted that the airspeed dropped to 80 mph He verified that the throttle was in full and then noticed that the airspeed dropped to 60 mph which he said was 2 mph above the clean stall speed While maintaining 60 mph with full power the airplane began descending At this point the pilot noticed t
233. t recent annual inspection was completed December 9 2013 at 7 945 aircraft hours At 1050 the weather conditions reported at Millington Regional Jetport NQA 20 miles southwest of M04 included few clouds at 2 500 feet 10 miles of visibility and winds from 180 degrees at 9 knots The temperature was 35 degrees C the dew point was 17 degrees C and the altimeter setting was 29 98 inches of mercury An NTSB meteorologist observed that the winds aloft at the airplane s cruising altitude of 6 000 were from about 225 degrees at 20 to 25 knots Throughout the flight the airplane maintained an approximate ground track of 225 degrees Examination of photographs revealed the airplane came to rest in standing water among wooded terrain The cockpit and cabin areas were destroyed by impact and had also been cut by first responders The empennage appeared separated from the fuselage but still attached by cables The left wing appeared to have separated before the airplane came to rest According to detectives of the Tipton County Sheriff s Office there was no odor of fuel no evidence of fuel in the airplane and no evidence of fuel spillage at the scene The Chief of Detectives stated she did not order any environmental remediation of the crash site due to fuel spillage because there was nothing to remediate Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 86 Prepared From Official Records of the NTSB By Al
234. t track to the right 1933 55 N7147P requested to return to Abilene 1934 04 N7149P reported we ve lost our suction and our attitude indicator Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 73 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database 1934 20 the controller responded and gave clearance to retum to Abilene 1934 52 radar showed that N7147P s rate of right tum increased 1935 10 radar showed that N7147P was at 9 300 feet and the remainder of the radar returns showed an erratic flight path 1935 30 radar showed N7147P was at a transponder reported altitude of 10 300 feet and it then began descending 1935 38 the controller asked N7149P to verify that he was VFR 1935 43 N7147P reported affirmative we are v f r but we are having trouble four seven there was a change in the sense of urgency noted in the voice of the pilot and the end of the transmission was cut off 1935 46 the controller responded giving the location of the nearest airport however there were no further communications received from N7147P 1936 14 radar showed N7147P was at a transponder reported altitude of 5 300 feet 1936 23 the last radar return showed N7147P was at a transponder reported altitude of 3 600
235. t wing attach point but separating from the forward wing attach point Extensive spanwise leading edge aft crushing was present The wing s flight control surfaces separated from their respective attach points Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 49 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database The airplane s severed left wing was suspended in the tall trees almost directly above the main wreckage site and exhibited spanwise leading edge aft crushing with multiple elliptical impact areas The wing s flight control surfaces remained attached to their respective attach points The left wing lift strut remained attached to the wing but separated at the fuselage The airplane impacted on its nose and the tips of both floats The tips of both floats showed impact damage and the float support structure collapsed Extensive impact damage was evident to the airplane s firewall and right side of the cockpit area The forward right hand door remained attached to its attach points but the door post and forward fuselage exhibited crushing damage The empennage was bent to the right approximately 90 degrees just forward of the horizontal stabilizer The left horizontal stabilizer exhibited le
236. tablished on final approach at the proper glidepath but the descent rate again increased and the wind started to gust on short final approach The airplane subsequently touched down prior to the approach end of runway 14 in a grass drainage basin of a perpendicular runway During the landing the right wing struck the ground and the nosegear collapsed before the airplane came to rest upright in the basin With the exception of the inability to restart the right engine the instructor did not report any preimpact mechanical malfunctions with the airplane Examination of the airplane by a Federal Aviation Administration inspector revealed substantial damage to the right wing and fuselage The inspector did not observe any preimpact mechanical malfunctions Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS The instructor s failure to obtain the proper touchdown point in a multiengine airplane during a single engine approach in a strong gusty headwind Events 1 Enroute cruise Miscellaneous other 2 Landing Landing area undershoot 3 Landing Collision with terr obj non CFIT Findings Cause Factor 1 Aircraft Aircraft oper perf capability Performance control parameters Descent approach glide path Not attained maintained C 2 Personnel issues Task performance Use of equip info Aircraft control Instructor check pilot C 3 Environmental issues Conditions weather phenomena Wind High wind
237. tantial damage to the right wing and fuselage The inspector did not observe any preimpact mechanical malfunctions Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com Page 6 National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt ERA12LA503 07 27 2012 1535 EDT Regis N1572S Homerville GA Apt Homerville Airport HOE Acft Mk MdI BEECH 95 A55 Acft SN TC 316 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl CONT MOTOR 10 470 SERIES AcftTT 4890 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name SPREAD YOUR WINGS LLC Opr dba Aircraft Fire NONE Narrative On July 27 2012 about 1535 eastern daylight time a Beechcraft 95 A55 N1572S sustained substantial damage during a forced landing near Homerville Georgia The private pilot and passenger were not injured The airplane was registered to and operated by Spread Your Wings LLC under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed for the flight from Douglas Municipal Airport DQH Georgia to Flying Ten Airport 0J8 Archer Florida The flight originated from DQH at 1500 The pilot rep
238. ted The post accident sight of the selector handle coupled with the engine failure prompted the pilot to realize that he had likely forgotten to reset the selector to the BOTH position and that that was the likely cause for the power loss Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 35 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt ANC13LA029 03 06 2013 1730 AST Regis N1704U Bethel AK Apt N a Acft Mk Mdl CESSNA 207 Acft SN 20700304 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl CONT MOTOR IO 520 SERIES AcftTT 31644 Fatal 0 SerlInj 0 Fit Conducted Under FAR 135 Opr Name FLIGHT ALASKA INC Opr dba YUTE AIR ALASKA Aircraft Fire NONE Narrative On March 6 2013 about 1730 Alaska standard time a Cessna 207 airplane N1704U sustained substantial damage during a forced landing on snow covered tundra about 16 miles northeast of Bethel Alaska The airplane was operated as Flight 595 by Yute Air Alaska Anchorage Alaska as a visual flight rules scheduled passenger cargo flight under the provisions of 14 Code of Federal Regulations Part 135 The airline transport pilot and the two passengers were not injured Visual meteorological conditions p
239. that his most recent flight review as required by 14 CFR 61 56 was completed on March 20 2011 He was issued a third class airman medical certificate with a restriction for corrective lenses on January 12 2012 AIRCRAFT INFORMATION The accident glider was a Jonker Sailplanes model JS 1B serial number 24 It was a single seat high performance sailplane constructed mainly of composite materials Registration data indicated that the glider was manufactured in 2011 and was issued an airworthiness certificate on July 27 2011 The pilot reported that the airframe had accumulated approximately 100 hours total time in service at the time of the accident METEOROLOGICAL CONDITIONS Weather conditions recorded by the 0EO Automated Weather Observing System AWOS located about 22 miles south southwest of the accident site at 1255 were wind from 230 degrees at 6 knots visibility 10 miles scattered clouds at 7 500 feet agl temperature 21 degrees Celsius dew point 1 degree Celsius and altimeter 30 04 inches of mercury WRECKAGE AND IMPACT INFORMATION The glider impacted a mesa in rural New Mexico 23 miles and 23 degrees from 0E0 Examination of the glider on scene revealed that the empennage was partially separated from the tail boom at a point near the leading edge of the vertical stabilizer The tail boom had a longitudinal split from the point of separation with the tail running forward toward the cockpit The forward fuselage had crushing damage in
240. the 9 12 o clock position of the rotor disk In the Operator Owner Recommendation section of the NTSB Pilot Operator Aircraft Accident Incident Report the pilot owner stated that he cannot conceive why the relieved pilot would knowingly approach the aircraft in a position he knew well to be the lowest point of the rotor system This was not our practice and absolutely not his habit The weather conditions reported at an airport about 26 nautical miles northwest of the accident location around the time of the accident included calm wind Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 53 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database According to the helicopter manufacturer representative the main rotor height can vary depending on how the helicopter landing gear was serviced In addition depending on the position of the cyclic the main rotor can descend lower than six feet when the main rotor is operating According to the FAA Helicopter Flying Handbook The cyclic pitch control is usually projected upward from the cockpit floor between the pilot s legs or between the two pilot seats in some models This primary flight control allows the pilot to fly the helicopter in any direction of
241. the controller must remain vigilant for such situations and issue a safety alert when the situation is recognized 2 Recognition of situations of unsafe proximity may result from MSAW E MSAWILAAS automatic altitude readouts JO 7110 65U 2 9 12 b Aircraft Conflict Mode C Intruder Alert Immediately issue initiate an alert to an aircraft if you are aware of another aircraft at an altitude which you believe places them in unsafe proximity If feasible offer the pilot an alternate course of action c When an alternate course of action is given end the transmission with the word immediately Section 2 4 15 EMPHASIS FOR CLARITY Emphasize appropriate digits letters or similar sounding words to aid in distinguishing between similar sounding aircraft identifications Additionally a Notify each pilot concerned when communicating with aircraft having similar sounding identifications b Notify the operations supervisor in charge of any duplicate flight identification numbers or phonetically similar sounding call signs when the aircraft are operating simultaneously within the same sector Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 99 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database
242. tical Department Mobile Alabama for disassembly and inspection On May 15 2013 under the supervision of an FAA District Office MIDO Safety Inspector the engine was disassembled and examined at Continental Motors The examination revealed that most of the engine s major intemal damage was associated with the number one piston assembly According to a report prepared by the manufacturer s investigator the number one piston was fractured at the piston pin bore releasing the number one rod and piston pin assembly at the small end The unsupported number one rod and piston pin assembly caused damage to the rear section of the crankcase and camshaft The number one rod had released from the crankshaft and exhibited extreme mechanical damage The number one rod was found in the oil sump There were no signs of lubrication distress Portions of the piston skirt were recovered from the oil sump and inspected in the CMI lab The number one cylinder piston rod and sump contents were retained in bonded storage The number one piston assembly connecting rod and associated pieces were shipped to the National Transportation Safety Board Materials Laboratory Washington DC An examination of the number one piston assembly at the NTSB laboratory on February 12 2014 revealed fatigue fractures in both connecting rod retaining bolts Damage to the piston and wrist pin were consistent with damage following the release of the connecting rod from the crankshaft A
243. to require their maintenance personnel to track maintenance actions on both the aircraft s discrepancy log and the aircraft logbooks 4 A comprehensive process for determining whether or not a soft field is safe for operations or too soft has been developed by EKU Additionally the EKU Aviation operations SOP will be modified to amplify soft field training It will reinforce the requirement that all soft field maneuvers will be demonstrated and practiced on a hard surface before introducing actual soft field approaches landings and takeoffs to a soft field 5 On April 19 2012 EKU stood down from all flight operations Before returning to an operational status the EKU chief flight instructor conducted safety stand down meetings with both maintenance personnel and all flight instructors Additionally all instructors were directed to re review emergency landing procedures with all of their students on their very next flight 6 On May 18 2012 EKU held an all hands safety stand down for students and instructors to discuss the accident 7 The EKU chief flight instructor developed an emergency landing pattern ELP for EKU s Cessna 172s and Seneca Ill aircraft based on the U S Navy s Precautionary Emergency Landing PEL procedure Altitudes to cross high key perpendicular to the runway centerline and low key high abeam have been developed practiced and taught as another method of dealing with rough running engine versus entering the airport
244. ts separate from the helicopter as the helicopter flew overhead Witnesses were also consistent in reporting that the empennage section of the helicopter then departed the aircraft before impact with the ground One witness standing about 20 feet from the impact stated that the helicopter was inverted over the industrial buildings before it impacted two palm trees about 25 feet above ground level a pickup truck and then the ground Another witness stated that the postcrash fire started after the pilot and passenger were extracted from the helicopter or about 5 minutes after the initial impact He also stated that the helicopter was inverted over the industrial buildings PERSONNEL INFORMATION According to Federal Aviation Administration FAA records the pilot held a commercial pilot certificate with ratings for helicopter and airplane single engine land issued on October 23 2003 The pilot was issued a mechanic certificate on October 23 2003 with ratings for airframe and power plant The pilot was issued a first class medical certificate on February 25 2013 with the medical restriction must wear corrective lenses for distant and possess glasses for near vision FAA records also indicated that in February of 2013 the pilot reported 6 840 total flight hours and 76 flight hours in the previous 6 months The pilot s logbooks were not retrieved AIRCRAFT INFORMATION The four seat skid type landing gear helicopter serial number 1610 was manufac
245. tude and heading indicators that can fail progressively As the gyroscopes slow down they may wander which if connected to the autopilot can cause incorrect movement or erroneous indications which the pilot may misinterpret and transform a normally benign situation into a hazardous situation with the potential to lead the unsuspecting pilot into a dangerous unusual attitude that would require a partial panel recovery It is important that pilots practice instrument flight without reference to the attitude and heading indicators in preparation for such a failure An obscured horizon a dark scene spread with ground lights and stars can provide inaccurate visual information or false horizon for aligning the aircraft correctly with the actual horizon The disoriented pilot may place the aircraft in a dangerous attitude In moderate unusual attitudes the pilot can normally reorient by establishing a level flight indication on the attitude indicator However the pilot should not depend on this instrument if its upset limits may have been exceeded or it may have become inoperative due to mechanical malfunction As soon as the Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 76 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety
246. tured in 2006 The helicopter was powered by a Lycoming O 540 F1B5 225 horsepower engine serial number L 26556 40A Review of the aircraft and engine logbooks revealed the last annual inspection was conducted on December 04 2012 at an hour meter time of 749 4 total hours of operation The hour meter was located at the crash site and read 760 2 hours According to FAA records the helicopter was issued a standard airworthiness certificate on October 21 2011 According to the helicopter logbook the manufacturer s order form indicated that both spindle bearings were replaced refurbished and installed on the new rotor blades When this was completed the new rotor blades automatically incurred a reduced service life when installing used spindles The remaining time on the new rotor blades was reduced from 2 200 hours or 12 years whichever comes first to match the used spindles which had about 1 439 hours or 5 years remaining whichever came first The rotor blades and spindles expire as a pair The mechanic was hired to conduct the re installation of the main rotor blades on the helicopter on April 3 2013 The course of the day was spent installing the blades making adjustments to the pitch change links and performing a track and balance procedure that adjusts the rotor blades for the smoothest operation on the rotor system An approximate uneventful 1 hour test flight was conducted prior to the accident flight METEOROLOGICAL INFORMATION The TMB
247. urn in a 45 to 60 degree angle of bank He noticed that two landing gear were down and from his vantage point thought that the airplane had a tail wheel The airplane descended a couple of hundred feet during the tum He noted that it was below the tree line at that point and it continued the turn to a southwesterly heading It started up a valley between two ridgelines and disappeared from his sight behind the nearest one He stated that he had encountered downdrafts in that area on occasion and didn t think that this was an area where one should fly low He estimated that the airplane flew about 500 yards out of his sight about 20 seconds after it disappeared he saw white then gray then black smoke The pilot s friend who is also a pilot observed the airplane slowly flying around his home and stated that he recognized it as his friend s airplane He noted that the landing gear and partial flaps were down and he observed a hand wave out the pilot s window Shortly thereafter the airplane turned to the west and the gear began to retract He returned to his previous activities and within seconds heard a whump followed by silence He moved to a better vantage point and observed smoke in the direction of his last observation of the airplane PERSONNEL INFORMATION A review of Federal Aviation Administration FAA airman records revealed that the 72 year old pilot held a private pilot certificate with ratings for airplane single engine land multi
248. us Pending Eng Mk Mdl LYCOMING 0 235 C1B AcftTT 5325 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name JOHN THOMASON Opr dba Aircraft Fire NONE Summary The pilot reported that during the flight he was following an interstate highway and that he then turned west to intercept a state highway and head toward his destination He was flying about 1 000 feet above mountainous terrain when he became lost and disoriented while trying to navigate using maps and GPS He then thought that the airplane was losing altitude Subsequently he concentrated on the terrain rather than direction decided to make an off airport landing and landed the airplane in a dry river bottom During the landing roll the nosewheel dug into soft dirt and the airplane nosed over Postaccident engine and airframe examinations revealed no evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS The pilot s geographic disorientation which resulted in an off airport precautionary landing in soft terrain and a subsequent nose over Events 1 Landing landing roll Off field or emergency landing 2 Landing landing roll Nose over nose down Findings Cause Factor 1 Personnel issues Task performance Use of equip info Use of charts Pilot C 2 Personnel issues Psychological Perception orientation illusion Geographic diso
249. ut out and retained for further examination by the NTSB Materials Laboratory Additionally the mating sections of the left wing were also sent to the NTSB Materials Laboratory for comparison purposes Examination of the cockpit revealed the airspeed indicator and tachometer were off scale low both needles of the cylinder head temperature gauge were at or just below the low end marking The exhaust gas temperature of one cylinder was indicating 1 200 degrees Fahrenheit while the other was indicating off scale low Examination of the engine which remained attached to its attach points on the airframe revealed the drive belt was in place and the engine rotated freely by hand Power train continuity was confirmed The exhaust was removed and no evidence of scoring was noted on the sides of the pistons Inspection of the carburetors revealed 1 bowl had some debris while the bowl of the other carburetor contained some fuel Inspection of the fuel pump revealed no evidence of preimpact failure or malfunction Examination of the wooden propeller which remained attached to the engine revealed one blade was fractured three pieces were recovered along the debris field The other blade MEDICAL AND PATHOLOGICAL INFORMATION Postmortem examinations of the pilot and passenger were performed by the District 5 Medical Examiner s Office Leesburg Florida The cause of death for both was listed as Multiple blunt force injuries due to airplane crash Forensic to
250. ut the descent Further as the airplane got closer and the traffic advisories were issued the helicopter pilot began tuming north which brought the helicopter directly into the path of the approaching airplane while simultaneously placing the airplane behind her immediate field of vision Shortly after she sighted a silhouette of the airplane and propeller at her 4 o clock position She performed an evasive maneuver to the left but then felt the helicopter being struck Neither the airplane pilot nor the occupant observed another aircraft near the airplane before the collision Although the airplane pilot was not receiving traffic advisories from ATC it was still the pilot s responsibility to maintain a proper visual lookout to avoid other aircraft in the area The helicopter s left navigation light was inoperative when tested after the accident however this most likely did not affect the outcome because the left side of the helicopter would not have been visible to the airplane pilot at any point during the flight Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS The failure of both pilots to see and avoid each other during cruise flight which resulted in a midair collision Contributing to the accident was the failure of air traffic control personnel to issue the helicopter pilot a prompt and appropriate alternate course of action upon receiving a conflict alert Events 1 Enroute cruise
251. ved that her flight instructor s diligent flight training along with the Gleim material prepared her for her first solo During a telephone interview the student pilot stated that her flight instructor told her to perform touch and go landings for her first student solo flight She performed one touch and go landing and her flight instructor told her over the radio that the landing was great She then attempted a second touch and go landing during which the accident occurred The student pilot stated that she did not remember if her flight instructor was talking to her over the radio during landing rollout The student pilot said that she never lost consciousness during the accident and she did not remember what occurred during the accident sequence She said she received a black eye blood was running from her nose while the airplane was inverted and the left side of her face sustained injures She did not have any broken bones The student pilot said that the airplane was not equipped with a shoulder hamess and that her flight instructor had ensured that the airplane was in good condition The student pilot said that she will continue flying and wants to continue taking lessons from the flight instructor The student pilot said her flight instructor is a great instructor and the ground training she received from him was great She said that she talked to her flight instructor s students and they were happy with the flight instruction they r
252. xicology was performed on specimens of the pilot by the FAA Bioaeronautical Sciences Research Laboratory FAA CAMI Oklahoma City Oklahoma and also by Wuesthoff Reference Laboratory Wuesthoff Melboume Florida The toxicology report by FAA CAMI indicated testing for carbon monoxide and cyanide was not performed No volatiles were detected in the vitreous fluid and no tested drugs were detected in the liver specimen The Printed May 22 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 91 Prepared From Official Records of the NTSB By All Rights Reserved Air Data Research 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database toxicology report by Wuesthoff indicated the results were negative for volatiles and tissue immunoassay screen Unquantified amount of caffeine was detected and the carboxyhemoglobin saturation was 0 62 percent Iron 470 mcg g was detected and was above the reporting limit of 1 9 mcg g Additionally the following was detected in the vitreous fluid 18 2 mg dL urea nitrogen 0 53 mg dL creatinine 138 mEq L sodium 15 4 mEq L potassium 121 mEq L chloride and less than 10 mg dL glucose Forensic toxicology testing was performed on specimens of the passenger by Wuesthoff The results were negative for volatiles and urine immunoassay screen and unquantified amounts of caffeine a
253. ylight hours The wreckage was located about 2000 hours the same day PERSONNEL INFORMATION The pilot age 50 seated in the rear seat was the holder of a private pilot certificate with airplane single engine land rating issued on April 23 2012 On the application for the private pilot certificate she listed a total time of 47 3 hours She held a third class medical certificate with a restriction to have available glasses for near vision issued October 25 2011 The front seat occupant was not a FAA certificated pilot The son of both occupants was asked if his parents performed aerobatic maneuvers and he reported they never did He reported they fly straight and level from point A to B AIRCRAFT INFORMATION The airplane was built from a kit manufactured by Quad City Ultralight Aircraft Corporation On January 13 1992 the kit was sold to a company in Florida and was built as model Challenger II and was designated serial number CH20192 0779B It was powered by a 52 horsepower Rotax 503 dual carburetor dual ignition engine and equipped with a wooden fixed pitch propeller An operating Light Sport Aircraft Special Airworthiness Certificate was issued on January 7 2008 On the application for U S Airworthiness Certificate the airframe total time was listed at 300 hours According to FAA records the pilot and front seat occupant purchased the airplane on August 21 2011 The FAA IIC reported that the maintenance records were not located howev

General Aviation Reports - John Eakin

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