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General Aviation Reports - John Eakin

1. 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 WPR12FA191 05 02 2012 1140 MST Regis N350TL Phoenix AZ Apt N a Acft Mk Mdl HUGHES 269C UNDESIGNAT Acft SN 680694 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING HIO 360 DIA AcftTT 1582 Fatal 0 Serlnj 1 Fit Conducted Under FAR 091 Opr Name CANYON STATE AERO Opr dba Aircraft Fire NONE AW Cert STN Summary When the pilot was about 2 minutes from his destination at an altitude of about 500 feet above ground level he sensed a vibration through the back of his seat and in the anti torque pedals The vibration was followed by a right yaw that the pilot could not correct with a pedal input As the pilot attempted to maintain level flight he heard a metallic clunking behind him He looked back and saw what he described as the tail rotor losing rotor speed The pilot maintained forward flight by countering the right yaw with left cyclic input while he located a cul de sac in a residential neighborhood in which to land The pilot entered an autorotation and during the descent the helicopter impacted the roof of a house and an adjacent brick wall Witnesses reported that the helicopter d
2. Fuel Tanks Maintenance records indicated that in April 2013 the helicopter had been retrofitted in accordance with RHC R44 Service Bulletin SB 78B inclusion of fuel tank bladders and both SB 67 and SB 68 replacement of rigid fuel lines and clamps with flexible hardware Examination of both fuel tanks revealed that their outer skin surfaces had buckled and been breached during the accident sequence however the inner bladders remained intact For the main fuel tank the fuel tank supply line and aux to main line fittings remained attached to the bladder with their flexible hose portions broken away at the fitting Additionally the flexible portion of the vent interconnecting line was severed at its junction with the tank skin For the auxiliary fuel tank the flexible portion of the vent interconnecting line had pulled away from its fitting nipple ADDITIONAL INFORMATION Main Rotor Gearbox Chip Light Indicator The RHC Maintenance Manual for the R44 series recommends draining and straining the gearbox oil and inspecting the chip detector following a chip light indication In particular it recommends the following corrective action if no significant debris is found on the chip detector For fuzz particles Clean chip detector with compressed air or toothbrush do not use magnet and reinstall Normal wear especially new gearboxes will Printed January 15 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 67 Pre
3. 2 Landing aborted after touchdown Runway excursion 3 Landing aborted after touchdown Collision during takeoff land Findings Cause Factor 1 Aircraft Aircraft oper perf capability Performance control parameters Descent approach glide path Incorrect use operation C 2 Personnel issues Task performance Use of equip info general Pilot C Narrative On September 19 2012 about 0910 central daylight time a Beechcraft model A23 24 airplane N3629Q was substantially damaged during an aborted landing at Perry County Municipal Airport TEL Tell City Indiana The commercial pilot and two passengers were not injured The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 without a flight plan Day visual meteorological conditions prevailed for the personal flight that originated from Breckinridge County Airport 193 Hardinsburg Kentucky about 0900 The pilot reported that he made a straight in approach to runway 31 4 400 feet by 75 feet asphalt after a short flight of about 10 minutes He stated that there was no appreciable wind during the landing attempt with the wing flaps fully extended He reported the airplane landed about 1 3 down the runway After touchdown he retracted the wing flaps and applied brake pressure in an attempt to slow the airplane He reported that the airplane did not seem to decelerate normally during the landing roll because of the downslope of the
4. AIRCRAFT INFORMATION The accident aircraft was a single seat strut braced low wing monoplane specifically designed by the manufacturer for aerial application use The tail cone and empennage assemblies were of semi monocoque construction From the tailcone forward a welded tubular steel structure was incorporated which was covered with aluminum skin panels It was equipped with a liquid dispersal system which included a fiber glass reinforced plastic hopper which was located immediately forward of the cockpit and a conventionally configured heavy duty landing gear system which consisted of chrome vanadium steel main landing gear springs and a spring steel tubular tail wheel spring with a steerable tailwheel It was powered by a normal aspirated 230 horsepower six cylinder horizontally opposed air cooled engine The interior of the airplane was intemally corrosion proofed and the external finish was acid resistant According to FAA and maintenance records the airplane was manufactured in 1973 On April 27 1973 the airplane was sold by the Cessna Aircraft Company to an operator in Montana and was registered as N21796 On July 24 1973 the airplane was sold to an operator in Canada and was removed from the United States Civil Aircraft Registry and registered in Canada as C FFZI On July 12 1982 the airplane was involved in an accident during landing which damaged the landing gear one of the wings and the vertical stabilizer On Mar
5. which were forwarded to the NTSB Vehicle Recorders Laboratory Washington D C for data download The Stearman pilot was utilizing a Garmin GPSMAP 96C however flight information for the Stearman could not be extracted due to the record function having been disabled The RV 12 pilot was utilizing a Garmin GPSMAP 496 which captured the accident flight and revealed that the RV 12 overflew the airport at a GPS altitude of about 2 400 feet and entered the downwind leg of the traffic pattern for runway 13 about 1054 The RV 12 was at a GPS altitude of about 1 800 feet a heading of about 310 degrees and an airspeed of about 85 knots at the time of the collision FAA FAR 91 113 Right of way rules Except water operations stated in part b General When weather conditions permit regardless of whether an operation is conducted under instrument flight rules or visual flight rules vigilance shall be maintained by each person operating an aircraft so as to see and avoid other aircraft Printed January 15 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 8 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 WPR14CA063 12 07 2013 0 Regis N3981C Bryon CA Acft Mk MdI BURKHART GROB G 103 TWIN II A
6. www airsafety com National Transportation Safety Board Aircraft Accident Incident Database point of the aileron The separated wing section was about 15 feet in length and remained mostly intact The spar was fractured and splintered where it separated from the inboard section of the wing The metal aileron controls were fractured in overload and bent downward toward the underside of the wing The control tube tore through the wing fabric laterally from the connection point to the inboard most point MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot on April 1 2013 by South Plains Forensic Pathology P A Lubbock Texas The cause of death was determined to be blunt force injuries A toxicology report for the pilot was prepared by NMS Labs The results of toxicology testing of specimens from the pilot revealed the following gt gt 23 mg dL mg hg ETHANOL detected in muscle gt gt CAFFINE detected in muscle According to Federal Aviation Administration FAA Civil Aerospace Medical Institute the presence of Ethanol is consistent with postmortem putrefaction No Tested for Drugs were detected in the liver ADDITIONAL INFORMATION BGA Mandatory Aircraft Inspection 042 07 2004 Issue 3 As a result of a Ka7 glider wing failure in England in 2004 the United Kingdom Air Accidents Investigation Branch AAIB conducted an investigation and the British Gliding Association BGA issued a mandatory wing inspectio
7. ON position Fire partially consumed the manual and auxiliary fuel pumps Engine A borescope inspection revealed no mechanical deformation to the valves cylinder walls or intemal cylinder head Investigators manually rotated the crankshaft with the cooling fan and obtained thumb compression on all cylinders in firing order Investigators identified no mechanical anomalies with the airframe or engine during the wreckage examination ADDITIONAL INFORMATION Fuel Tanks Robinson Helicopters are equipped with either one or two metal all aluminum main and auxiliary fuel tanks which are installed above the engine firewall and on each side of the main rotor gearbox In numerous instances the fuel tanks have been breached during accidents leaked fuel and a post crash fire occurred In a number of cases occupants have survived the initial accident only to sustain serious or fatal injuries in the post crash fire On December 20 2010 RHC issued R44 Service Bulletin SB 78 recommending the installation of fuel bladders Robinson R44 SB 67 and SB 68 address other fuel system crashworthiness components fuel hose supports and flexible fuel lines designed to minimize the possibility of a post crash fire in the R44 series Although not required the design changes detailed in this service bulletin demonstrated compliance to a portion of the fuel system crashworthiness regulations in Title 14 CFR Part 27 952 On September 28 2012 RHC issued revision B to S
8. The airplane was en route to its destination when witnesses observed it making several turns before it pitched nose up climbed rolled to the right and then descended nose down to the ground Several witnesses observed airplane components floating to the ground behind the airplane All witnesses reported hearing loud engine noises throughout the event Impact signatures were consistent with a nose down attitude with a near vertical descent angle Distribution of the airplane wreckage supported the observation by eyewitnesses of an in flight breakup An examination found that both wings failed in overload with positive wing loading In addition there was no evidence of flight control over travel or flutter It could not be determined whether the pilot intended to perform the abnormal maneuver that resulted in an overload of the airplane or if it was the result of a physiological issue Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS The pilot s maneuver which exceeded the airplane s structural limit and resulted in an in flight breakup Events 1 Maneuvering Unknown or undetermined 2 Maneuvering Loss of control in flight 3 Maneuvering Aircraft structural failure Findings Cause Factor 1 Aircraft Aircraft oper perf capability general general Not specified C 2 Aircraft Aircraft structures Wing structure general Capability exceeded C 3 Personnel issues Action decision
9. information what direct effect the marijuana alone may have had on the pilot s judgment and psychomotor functioning however the combination of marijuana oxycodone and gabapentin likely significantly impaired the pilot s judgment and contributed to his failure to ensure the airplane had sufficient fuel to complete the planned flight Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS The pilot s inadequate preflight planning which resulted in fuel exhaustion and a subsequent total loss of power in both engines during cruise flight Contributing to the accident was the pilot s use of prescription and illicit drugs which likely impaired his judgment Events 1 Prior to flight Preflight or dispatch event 2 Enroute cruise Loss of engine power total 3 Emergency descent Off field or emergency landing 4 Emergency descent Collision with terr obj non CFIT Findings Cause Factor 1 Personnel issues Task performance Planning preparation Fuel planning Pilot C 2 Personnel issues Physical Impairment incapacitation Prescription medication Pilot F 3 Personnel issues Physical Impairment incapacitation lllicit drug Pilot F Narrative On December 24 2012 about 1435 eastern standard time a Piper PA 31 350 N78WM was substantially damaged when it collided with terrain during a forced landing following a loss of power in both engines near Leesburg Florida The private pilot wa
10. no flight plan was filed for the personal flight The cross country flight originated from Tehachapi Califomia at 1643 with an intended destination of FCH Preliminary information provided by the Federal Aviation Administration FAA revealed that the pilot was receiving Visual Flight Rules VFR flight following with Air Traffic Control ATC When the flight was about 10 miles south of the airport the pilot notified ATC that he had the airport in sight Subsequently ATC cancelled flight following and approved the pilot to change frequencies Multiple witnesses located adjacent to the accident site and airport reported observing the accident airplane enter the airport traffic pattern for runway 30 A witness located on the ramp area of the airport stated that the airplane initially captured his attention when it landed hard about midway down the runway then proceeded to takeoff Witnesses observed the airplane continue on a northwesterly heading and maneuver for landing on runway 12 where they observed the airplane fly at a high rate of speed about 10 to 15 feet above ground level agl The witnesses stated that the airplane entered a climb about three quarters down the runway and continued to the southwest where a series of tums were performed Witnesses further stated that they then observed the airplane approach runway 30 Two witnesses located about mid field of the airport reported observing the airplane fly along the runway about 100 feet agl and n
11. the airplane s forward engine firewall sustained substantial damage The pilot reported no preimpact mechanical failures or malfunctions with the airframe or engines that would have precluded normal operation Printed January 15 2014 Page 36 an airsafety com e product 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 WPR13CA413 09 15 2013 1951 PDT Regis N712SB San Luis Obispo CA Apt San Luis County Rgnl SBP Acft Mk MdI CESSNA T310R Acft SN 310R0122 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl CONTINENTAL TSIO 520 SERI AcftTT 4795 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name SINGER NATHAN Opr dba Aircraft Fire UNK Narrative The pilot reported that during the landing roll of his second uneventful landing the right main landing gear started to shimmy He slowed the airplane and proceeded towards the nearest taxiway Before exiting the runway the pilot went to retract the flaps when he inadvertently raised the landing gear handle He quickly re lowered the landing gear handle however the right main landing gear had already started to retract The airplane veered to the right exited the runway surface and came to rest on the g
12. 29 99 inches of mercury WRECKAGE AND IMPACT INFORMATION Examination of the wreckage revealed that the right wing and landing gear structure was substantially damaged Examination of the right rudder pedal arm and right rudder bar were constructed of steel tubing Further examination revealed the presence of a plug in the top of the tubing which made up the right rudder pedal arm This plug appeared to be made of a flexible material similar to silicone sealant The left rudder pedal arm also contained a plug of this same silicone like material Both the right rudder pedal arm and the right rudder bar exhibited significant amounts of corrosion and it was discovered that the right rudder pedal arm had fractured just above its mounting location on the right rudder bar SURVIVAL FACTORS The pilot who was not wearing a helmet received minor injuries during the accident when his shoulder came into contact with the right side of the cockpit The cockpit was surrounded by a welded tubular steel structure and featured an emergency door release system to aid in egress and a fire extinguisher Cockpit seals and two cockpit pressurization scoops helped to lessen the possibility of contamination of the pilot by chemicals The instrument panel crash pad was covered in 7 inch black Ensolite and urethane bumper pads were bonded to the tubular steel structure above the cockpit door down the corner doorposts across the tubular structure behind the pilots head and a
13. 3 000 pounds standard temperature with the engine producing 65 percent power and the mixture set to best power fuel would be consumed at the rate of 10 5 gph at all altitudes up to 12 000 feet Fuel used to climb from sea level to 4 000 feet and sea level to 8 000 feet was 1 3 and 2 9 gallons respectively GPS data revealed that about the time of the initial fuel flow drop the airplane was about 17 miles west of Gene Wash Reservoir Airport Parker Dam Califomia and 15 miles northwest of Avi Suquilla Airport The airplane continued on the same track flying directly over Gene Wash Reservoir Airport about 6 minutes later Two minutes after overflying the airport the engine parameters dropped and the airplane began a descending right tum towards Avi Suquilla ADDITIONAL INFORMATION Gene Wash Reservoir was a private airport comprised of a single 2 200 foot long 30 foot wide asphalt airstrip Its presence was documented on the FAA Phoenix Sectional Aeronautical Chart The 77 year old pilot held a private pilot certificate and reported a total flight experience of 2 480 hours 50 of which were in the SR20 Printed January 15 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 Acciden
14. 350 degrees magnetic First responders reported that no fuel or fuel odor was present at the scene and that all of the airplane s fuel tanks appeared to be absent of fuel Printed January 15 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 The airplane was subsequently recovered from the scene and examined at an aircraft recovery facility Control continuity was traced from the cockpit area through overload separations and cable cuts performed by recovery personnel to each of the flight control surfaces Measurement of the stabilator trim tab actuator revealed a position consistent with a slight deflection in the nose up direction The flaps were in the retracted position and the position of the left main landing gear door was consistent with the landing gear being extended at impact Trace amounts of fuel were observed in two of the airplane s six fuel tanks and within both fuel strainer bowls The fuel had an odor consistent with 100 low lead aviation gasoline and was absent of debris or water Each of the fuel filler port caps was intact and secure The fuel quantity float sensors were recovered from the left and right inboard and outboard fuel tanks for functiona
15. 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database constructed using scarf joints The fracture of the scarf joint in the upper layer of the lower spar cap was relatively flat with adhesive on the tapered surface The fracture appeared to be mainly cohesive with varying amounts of adhesive remaining on the surface and no evidence of wood or smooth adhesive interface from the mating side of the fracture The scarf joint fractures in both spar caps were similar Overall the fracture features were consistent with fracture under combined tension and torsion The adhesive holding the ribs was brittle and pieces continued to separate from the structure as the components were handled during the examination Markings on the ribs noted a date of 1959 Pieces of the spar ribs and skin were disassembled by hand with varying amounts of effort All of the wood material appeared mostly dry with no staining from moisture on most of the structure However mold growth and stains from moisture were observed at the leading edge of the wing on the interior of the leading edge skin and adjacent structure Printed January 15 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 Natio
16. Angle of Climb Speed 86 KIAS at sea level to 92 KIAS at 20 000 feet with obstacle3 Best Rate of Climb Speed With Wing Flaps Up 111 KIAS at sea level and 7450 pounds The manufacturer s emergency procedure for ENGINE FAILURE DURING TAKEOFF Speed below 100 KIAS or Gear Down 1 Throttles CLOSE IMMEDIATELY2 Brake or Land and Brake AS REQUIRED The manufacturer s emergency Printed January 15 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 procedure for ENGINE FAILURE AFTER TAKEOFF Speed above 100 KIAS with Gear Up or In Transit 1 Mixtures FULL RICH2 Propellers FULL FORWARDS Throttles FULL FORWARD4 Landing Gear CHECK UP5 Inoperative Engine a Throttle CLOSEb Mixture IDLE CUT OFFc Propeller Feather6 Establish Bank 5 degrees toward operative engine7 Climb to Clear 50 Foot Obstacle 100 KIAS8 Climb at One Engine Inoperative Best Rate of Climb Speed 111 KIAS9 Trim Tabs ADJUST 5 degrees toward operative engine 10 Inoperative Engine SECURE as follows a Fuel Selector OFF Feel for Detent A WARNING at the end of the procedure stated The propeller on the inoperative engine must be feathered landing gear retracted and wing fla
17. F 5 Environmental issues Conditions weather phenomena Temp humidity pressure High density altitude Effect on operation 6 Not determined Not determined general general Unknown Not determined Narrative HISTORY OF FLIGHT On August 1 2012 approximately 1400 eastern daylight time a Luscombe 8A N2761K was substantially damaged when it impacted the ground when control was lost during takeoff from Albert Whitted Airport SPG St Petersburg Florida The private pilot owner was fatally injured and the flight instructor sustained serious injuries Visual meteorological conditions prevailed and no flight plan was filed for the flight which was originating at the time of the accident The instructional flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91 The flight instructor was interviewed following the accident and also provided a written statement recounting the events of the accident flight He stated that a Printed January 15 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 preflight inspection of the airplane revealed no anomalies and the engine start and pre takeoff checks were performed with no discrepancies n
18. Lycoming fuel injected O 540 AE1A5 engine It was involved in a hard landing in Broomfield Colorado on July 23 2011 where it sustained substantial damage to the firewall and tail rotor assembly See NTSB accident report CEN11CA511 Following the accident the helicopter was disassembled and transported to the repair facility in Redlands where it was repaired fuel tank bladders were installed and an annual inspection was performed The original main rotor gearbox was utilized for the repair and serviced with new gearbox oil after completion of a 500 hour flush and drain The maintenance logbooks revealed that the annual inspection was completed on April 15 2013 at which time the helicopter had accrued a total flight time of 1 541 4 flight hours and an hour meter time of 1 143 4 hours The hour meter indicated 1 145 6 hours at the accident site WRECKAGE AND IMPACT INFORMATION The helicopter came to rest at an elevation of 1 189 feet msl on the west slope of the ridge about 5 feet downhill from the landing site The general area overlooked the Roosevelt Municipal Golf Course and Vermont Canyon Tennis Courts about 300 feet below The main cabin remained largely intact with the tailboom bent 45 degrees upwards at the bulkhead seam Printed January 15 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 Helo
19. 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 WPR13LA101 01 24 2013 1545 PST Regis N18690 Matlock WA Apt Sanderson Field Airport SHN Acft Mk Mdl CESSNA 150L Acft SN 15074044 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl CONT MOTOR O 200 SERIES AcftTT 5574 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name ANDREW HANSEN Opr dba Aircraft Fire NONE Summary The student pilot reported that during his first solo cross country flight the weather started to deteriorate He descended to a lower altitude to avoid clouds and proceeded toward the nearest airport However when he tried to level off at the lower altitude the airplane continued to descend at a rate of about 700 feet per minute The pilot applied full engine power and ensured that the throttle was positioned for full power the mixture was full rich and the fuel selector was on both fuel tanks The airplane continued to descend so the pilot elected to land on a nearby road While on the base leg for the landing the pilot applied carburetor heat During the landing flare the left wing struck a road sign the airplane departed the road and came to rest inverted about 20 feet from the road A postaccident examination and engine run revealed no mechanical f
20. Transportation Safety Board Aircraft Accident Incident Database Accident Rpt CEN14FA110 01 10 2014 1948 EST Regis N3829G Waterford MI Apt Oakland County International A PTK Acft Mk Mdl CESSNA 310R Acft SN 924 Acft Dmg DESTROYED Rpt Status Prelim Prob Caus Pending Fatal 1 Serin 0 Fit Conducted Under FAR 091 Opr Name ROYAL AIR FREIGHT INC Opr dba Aircraft Fire GRD Narrative On January 10 2014 about 1948 eastem standard time a Cessna 310R N3829G impacted trees and terrain about 1 500 feet west of the approach end of runway 9R 6 521 feet by 150 feet asphalt at Oakland County International Airport PTK Pontiac Michigan during an instrument landing system approach to the runway Night instrument meteorological conditions prevailed at the time of the accident The airplane was destroyed by impact forces and post impact fire The commercial pilot sustained fatal injuries The airplane was registered to and operated by Royal Air Freight Inc as Flight 907 under 14 Code of Federal Regulations Part 91 The positioning flight was operating on an instrument rules flight plan and departed from Fulton County Airport Brown Field FTY Atlanta Georgia about 1701 and was destined to PTK Printed January 15 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 inf
21. capable of a 500 foot per minute rate of climb with only one operating engine on the day of the accident As found the airplane was not configured in accordance with the after takeoff checklist or the engine failure after takeoff checklist Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS The pilot s failure to follow established engine out procedures and to maintain a proper airspeed after the total loss of engine power on one of the airplane s two engines during the initial climb Contributing to the accident was the total loss of engine power due to a loss of torque on the crankcase bolts for reasons that could not be determined because of impact and fire related damage to the engine Events 1 Initial climb Loss of engine power partial 2 Initial climb Loss of control in flight 3 Uncontrolled descent Collision with terr obj non CFIT 4 Post impact Fire smoke post impact Findings Cause Factor Personnel issues Task performance Use of equip info Use of checklist Pilot C Aircraft Aircraft systems Landing gear system Gear extension and retract sys Incorrect use operation C Aircraft Aircraft oper perf capability Performance control parameters Engine out control Incorrect use operation C Personnel issues Action decision Action Incorrect action performance Pilot C Aircraft Aircraft power plant Engine reciprocating Recip eng front section Damaged degraded F Not
22. 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 The main wreckage was located about 200 feet down a slope off the east side of the highway The right wing was detached and located on the highway near the FIPC The wreckage debris path originated near the area of the wire strike and extended to where the main wreckage was located The wreckage debris was located within 300 feet from the point of impact The fuselage left wing and engine were located down the hill The wreckage came to rest inverted on a heading of about 310 degrees magnetic The measured elevation for the accident site was about 6 217 feet mean sea level The right wing was separated from the fuselage at the wing root area The wing exhibited a large impact compression in the middle portion of the leading edge of the wing which crushed most of the wing Rub marks nearly perpendicular to the wing and arcing were observed Two arcing holes with black color around them were observed on the wing skin bottom The fuselage came to rest inverted and the left wing remained attached The left wing exhibited leading edge and wing tip damage The left and right stabilizers rudder and vertical stabilizer were separated from t
23. in length located in the grass about one foot from the right edge of the runway About 16 feet past the ground scar on a heading of approximately 187 degrees magnetic a small crater was observed in the runway surface Two abrasions dimensionally consistent with the diameter and chord of the propeller extended out from the crater The airplane came to rest about 20 feet past the crater The engine was displaced aft into the firewall and the cockpit area exhibited significant crush damage Fuel staining was observed on the runway surrounding the airplane The propeller remained attached to the engine and exhibited scratching and gouging along its leading edge One blade exhibited slight s bending approximately four inches from its tip The engine spark plugs were removed and exhibited normal wear The crankshaft was rotated by hand and powertrain continuity was confirmed from the propeller to the rear accessory gears and to the valve train The carburetor remained attached to the engine but was impact damaged and void of fuel The carburetor float bowl was absent of fuel water and debris The float was undamaged and the fuel intake screen was clear Flight control continuity was established from all flight controls to the cockpit area The instrument panel engine controls and flight controls exhibited significant impact damage The fuel selector valve was found in the off position and continuity of the fuel system was confirmed from the fuselage tank
24. instructor at SPG AIRPLANE INFORMATION According to FAA airworthiness records the airplane was manufactured in 1947 and registered to the owner in April 2012 The airplane was powered by a Continental A 65 8 65 hp reciprocating engine Review of the airplane s maintenance logs revealed that its most recent annual inspection was completed on February 13 2012 at a total time in service of 1135 6 hours At the time of the accident the airplane had accumulated approximately 19 hours since the most recent inspection Although the airplane held a standard airworthiness certificate it met the definition of a Light Sport Aircraft as contained in Title 14 Code of Federal Regulations Part 1 1 making it eligible for operation by a pilot holding a valid drivers license in lieu of an FAA issued medical certificate According to weight and balance information contained in the airplane s maintenance logs the airplane had an empty weight of 838 lbs and a maximum allowable gross weight of 1 260 Ibs The autopsy report indicated that the pilot owner s weight was 203 Ibs The weight of the flight instructor as reported on his most recent FAA medical certificate was also 203 Ibs The calculated total fuel weight was approximately 84 Ibs at capacity resulting in an estimated gross weight of 1 328 Ibs at the time of the accident METEOROLOGICAL INFORMATION The 1400 weather observation at SPG included winds from 260 degrees at 8 knots 10 statute miles visibi
25. minutes the engine lost total power The pilot made a forced landing in mountainous terrain Subsequent examination of the airframe revealed that both fuel tanks were empty and neither the engine nor airframe exhibited indications of a fuel leak Examination of recorded data recovered from the airplane s flight displays revealed that its fuel consumption was appropriate for the flight profile The data further revealed that the airplane was approaching an airport as one of the tanks ran out of fuel The engine lost power however rather than landing the pilot continued the flight after switching to the other fuel tank The other tank ran out of fuel a short time later and the pilot performed a forced landing to a rocky outcropping where the airplane sustained substantial damage Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS The pilot s failure to perform an adequate preflight inspection which resulted in inadequate fuel for the flight and the subsequent fuel exhaustion and a total loss of engine power Contributing to the accident was the pilot s failure to land the airplane at the first indication of low fuel Events 1 Enroute cruise Fuel exhaustion 2 Enroute Loss of engine power total 3 Landing landing roll Collision with terr obj non CFIT Findings Cause Factor 1 Aircraft Fluids misc hardware Fluids Fuel Fluid level C 2 Personnel issues Task performance Inspect
26. model pilot operator handbook revealed that the airplane held 48 gallons of usable and 2 gallons unusable fuel and burned 9 16 gallons per hour at 65 percent power which would consume 48 09 gallons over a 5 hour 15 minute period The calculations did not include fuel used for takeoff and climbs missed approaches Printed January 15 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 ERA13FA096 12 24 2012 1435EST Regis N78WM Leesburg FL Apt Nia Acft Mk Mdl PIPER PA 31 350 Acft SN 31 7952047 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING LTIO 540 J2BD Fatal 1 Serin 1 Fit Conducted Under FAR 091 Opr Name FETCKO JOHN THOMAS Opr dba Aircraft Fire NONE Summary The pilot and the pilot rated passenger were flying from their home which was located at a residential airpark where no fuel services were available to an airport located about 37 miles away According to the passenger shortly after departure she queried the pilot about the airplane s apparent low fuel state The pilot responded that one of the fuel gauges always indicated more available fuel than the other and that if necessary they could use fu
27. no anomalies noted He stated that the takeoff roll was normal and the airplane lifted off in a reasonable distance He did notice about a 30 rpm drop during takeoff compared to other takeoffs but the engine speed was still within the normal operating range After gaining about 50 feet of altitude the airplane started losing power The pilot attempted to drop the chemical load in an effort to stay airborne but the airplane impacted an open field about one mile north of the airstrip The pilot stated that he thought the engine had lost almost all power by the time the airplane impacted the field The pilot did not mention using carburetor heat during the pre takeoff run up or during the power loss event Examination of the airplane and engine revealed no preimpact anomalies that would explain the loss of engine power Subsequent re examination of the engine also revealed no anomalies The carburetor and magnetos were sent to the NTSB investigator in charge for further examination The carburetor was disassembled and no anomalies were noted The right magneto was broken due to the impact however no anomalies were detected upon examination The left magneto was intact and produced spark when rotated At 0854 the weather conditions recorded at the Garden City Regional Airport Garden City Kansas about 15 miles east of the accident site included a temperature of 22 degrees Celsius and a dew point of 19 degrees Celsius According to the carburetor icing char
28. revealed the pilot died from blunt force and thermal injuries The FAA Bioaeronautical Sciences Research Laboratory Oklahoma City Oklahoma performed forensic toxicology on specimens from the pilot Thirty percent 30 carbon monoxide and 3 86 ug ml cyanide were detected in the specimens tested These levels are consistent with exposure to products of combustion TESTS AND RESEARCH The engines were examined in Mobile Alabama from February 19 to 22 2013 under the supervision of an FAA inspector Each was a 520 cubic inch six cylinder horizontally opposed air cooled fuel injected turbo charged geared engine that produced 375 horsepower at 3 350 rpm Examination of the No 2 right engine revealed no preimpact mechanical anomalies Examination of the No 1 left engine revealed signatures consistent with contact made between the piston domes and the valves The crankcase halves were separated and the No 1 cylinder main bearing was rotated and damaged and distorted severely with bearing fragments located in the oil sump Bearing material was extruded from its steel backing The No 3 main bearing displayed signatures consistent with accelerated wear and wiping of the Babbitt material Damage and signatures consistent with excessive heat due to oil starvation were displayed on the No 1 and No 3 main bearing journals as well as the No 1 and No 2 connecting rod journals The camshaft gear was damaged with five gear teeth found sheared f
29. runway The pilot stated that although there were no anomalies with the airplane s brake system he elected to abort the landing His intention was to return and land on runway 13 in order to take advantage of the runway s upslope He reported that as the airplane passed midfield he increased engine power for the aborted landing and that the engine was operating normally at takeoff power He stated that although the airplane accelerated to liftoff speed while still on the runway it did not clear a 10 foot high airport security fence located off the end of the runway Both wings were substantially damaged during the accident sequence The pilot reported no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation Additionally although he did not use maximum braking during the landing attempt the brakes had functioned normally while taxiing and during an engine run up at the departure airport A Federal Aviation Administration FAA inspector performed an on site investigation Examination of the runway overrun area showed tire tracks consistent with the tire width of the accident airplane The airplane had impacted a chain link fence located about 340 feet off the end of the runway The airplane continued then another 30 feet before coming to rest with the chain link fence entangled around the nose landing gear The postaccident examination did not Printed January 15 2014 an airsafety com e product Copyrig
30. to the fuel selector valve No fuel remained in the tank The carburetor heat control was found extended aft approximately 1 inch The mixture control was in the full rich position and the throttle control was in the full power position MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot by the Medical Examiner District Six Largo Florida According to the autopsy report the cause of death was blunt trauma Toxicological testing was performed on the pilot owner by the FAA Bioaeronautical Science Research Laboratory Oklahoma City Oklahoma Review of the toxicological report revealed that Carvedilol was detected in the liver and blood Citalopram was detected in the liver and blood N Desmethylcitalopram was detected in the liver and blood and Tamsulosin was detected in the urine and blood ADDITIONAL INFORMATION Given the atmospheric conditions the calculated density altitude at the time of the accident was approximately 2 070 feet According to the airplane s Owner s Handbook of Operation Due to reduced air density at higher altitudes wing lift and engine power are reduced with resulting performance reduction Take off and landing distances are increased and the rate of climb reduced Airworthiness Maintenance Bulletin No 40 issued by the Civil Aeronautics Administration in February 1941 addressed the issue of engine failures on takeoff in Luscombe 8A airplanes It stated The cause of these failures is bel
31. was a surgeon and was scheduled to perform surgery during the morning following the accident AIRCRAFT INFORMATION The four seat low wing retractable tricycle gear airplane serial number 28R 35693 was manufactured in 1970 It was powered by a Lycoming 10 360 200 horsepower engine equipped with a McCauley constant speed propeller Review of the airplane s logbooks revealed that its most recent annual inspection was completed on June 2 2012 At that time the airplane had accumulated 5 613 total hours of operation The engine had accumulated approximately 953 Printed January 15 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 hours since major overhaul The airplane was IFR equipped and had a Garmin 430 GPS that was wide area augmentation system WAAS enabled The airplane was also equipped with an STEC 30 autopilot that would fly the lateral portion of a GPS approach but not the vertical Additionally the pilot had a handheld Garmin Area 796 GPS METEOROLOGICAL INFORMATION The pilot obtained weather information and filed a flight plan with direct user access terminals about 1016 The weather the pilot obtained included the terminal forecast for New Castl
32. was removed and disassembled The plastic floats and needle were intact and appeared to be undamaged No debris was observed within the float bowl Air was applied to the venturi nozzle and air movement was noticed throughout the fuel passages Pliable debris similar to silicone was observed within the mixture metering sleeve The debris was removed and the carburetor was reassembled and subsequently reinstalled on the engine Silicone was also observed on the carburetor airbox assembly The source of the debris inside the carburetor was not determined The engine was started and ran without incident throughout various power settings before being shut down by utilizing the mixture cut off Review of the airplane maintenance logbooks revealed that on August 22 2013 at a tachometer time of 1 037 4 hours the carburetor was removed cleaned and the needle valve and seat were checked The carburetor was reinstalled on the engine and subsequently returned to service The engine had accumulated 1 5 hours tachometer time since the carburetor maintenance was performed Printed January 15 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 18 All Rights Reserved National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt CEN14C
33. winds Local law enforcement provided the IIC with statements of 3 witnesses who observed the accident Witness 1 who was located at his residence about 1 block north of the accident site reported that he heard the helicopter overhead and that it didn t sound right The witness stated that the engine was sputtering and sounded wrong and as he watched it it was rocking and teetering The witness added that it then lost altitude and nose dived toward the ground south of his location Witness 2 reported that he was in an alley south of the street where the helicopter crash landed and when he first heard the helicopter it did not sound right The witness stated that the engine was sputtering the rpms were increasing and decreasing and that the main rotor blade was also increasing and decreasing in speed The witness opined that the helicopter made a U turn overhead while losing altitude and that he lost sight of it due to trees and houses in the area He then proceeded to the accident site and began tuming all switches which were labeled ON and OFF to the OFF position but the engine kept running He also stated that the tail rotor blades were moving very fast Witness 3 who was a co worker of witness 2 and at the same relative location during the initial sighting of the helicopter reported that he noticed the helicopter turning around and going lower and that the engine didn t sound right like it was just barely idling He state
34. 0 degrees at 11 knots The temperature was 27 degrees C the dew point was 20 degrees C and the altimeter setting was 29 97 inches of mercury WRECKAGE INFORMATION The wreckage was examined at the accident site on December 9 2012 and all major components were accounted for at the scene The airplane was consumed by postimpact fire back to the aft pressure bulkhead The wing spars were intact and control cable continuity was established from the cockpit to the flight control surfaces Examination of the main landing gear actuators revealed positions consistent with a down and locked configuration Both engines were significantly damaged by postcrash fire All three propeller blades of the left engine were attached at the hub and in the feathered position The right engine s propeller blades were destroyed by impact and fire One blade was separated and not recovered The remaining blades showed positions consistent with low pitch Examination of the right fuel selector valve revealed that it was in the main position Examination of the left fuel selector valve revealed that it was in the off position Preliminary external and borescope examinations of both engines revealed continuity throughout and no mechanical anomalies The engines were retained for detailed examination at a later date MEDICAL AND PATHOLOGICAL INFORMATION The Office of the District Medical Examiner West Palm Beach Florida performed the autopsy on the pilot The autopsy
35. 1 2 ohms in the empty position and 45 ohms in the full position while the right outboard fuel tank sender displayed a resistance of 60 3 ohms in the empty position and 69 ohms in the full position The service manual stated that if any of the resistance tolerances could not be maintained the fuel sender unit must be replaced ADDITIONAL INFORMATION Fuel Availability The airplane was based at the pilot s home which was located on the grounds of a residential airpark FD44 There were no fueling facilities available at the airpark Review of a sectional aeronautical chart and the FAA Airport Facility Directory showed that the nearest airport that provided fuel services was Palatka Municipal Airport 28J Palatka Florida which was located about 15 nautical miles north of FD44 GPS Data A hand held GPS receiver was recovered from the wreckage and forwarded to the NTSB Vehicle Recorder Laboratory where its contents were successfully downloaded Review of the data showed that the unit had recorded the entirety of the accident flight beginning at 1409 The track data showed that the airplane subsequently departed FD44 at 1415 and climbed to a GPS measured cruise altitude of about 3 200 feet by 1422 During the climb the airplane flew generally southwest before it turned south and began heading toward LEE about 1423 At 1429 50 the pilot initially advised air traffic control that he was concemed about the airplane s fuel state when the airplane was
36. 2 1965 The glider was not approved for aerobatic maneuvers A review of the maintenance records revealed that the glider received major maintenance and repairs on May 30 1997 The most recent annual inspection was competed on April 1 2012 METEOROLOGICAL INFORMATION At 1553 an automated weather reporting station located at Lubbock Intemational Airport KLBB Lubbock Texas which was 32 miles southeast of the accident site reported wind variable at 4 knots visibility 10 miles few clouds at 9 000 feet broken cloud layer at 30 000 feet temperature 29 degrees Celsius C dew point minus 4 degrees C and the barometric pressure was 29 94 inches of mercury WRECKAGE AND IMPACT INFORMATION The glider impacted terrain on the northeast side of airport The main wreckage was located on flat terrain and situated on a southwesterly heading and was inverted The wooden components were mostly shattered and the metal tubular components were bent and damaged The empennage was twisted towards the cockpit and facing a southwesterly heading Portions of the right wing were located east and southeast of the main wreckage The outboard section of the right wing separated near the inboard attachment Printed January 15 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
37. 23 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Main Transmission Pinion and Aft Pinion Nut The material research engineer reported that approximately 0 3 inches of the aft portion of the main transmission pinion fractured transversely while fastened inside the aft pinion nut with the cotter pin still in place According to the engineer the exterior of the pinion possesses a series of splines that contact the interior splines of the drive spline The aft 2 inches of the exterior faces of the splines exhibited a shiny luster indicative of the outer surface having been worn off The drive faces of the exterior pinion splines showed fretting wear scars and material loss Upwards of 0 015 inches of material had been removed on the aft most 0 5 inches of the splines on the contact surfaces Chatter marks were visible on the pinion exterior just forward of where the splines taper off The engineer further reported that an examination of the mating fracture surfaces of the pinion revealed a small jog present on the fracture indicative of torsional failure The fracture surface was flat relatively smooth and perpendicular to the long axis of the part The surface exhibited fine crack arrest and ratchet marks indicative of progressive cracking He stated that a closer examination using a scanning electron microscope SEM revealed an oxidized surface with a pattern consiste
38. 4 inches Hg AERODROME INFORMATION In addition to a decision altitude of 355 feet msl for the GPS approach to runway 14 at SBY the decision height for the ILS approach to runway 32 was 253 feet msl 200 feet agl The decision altitude for the GPS approach to runway 22 at GED with LPV was 360 feet msl 310 feet agl GED was not equipped with an ILS approach The minimum descent altitude for the VOR RWY 27 approach at 33N was 520 feet msl 477 feet agl Further review of the published procedure revealed Procedure NA at night In addition to SBY both DOV and BWI were equipped with ILS approaches WRECKAGE INFORMATION Examination of the wreckage by an FAA inspector revealed that the airplane impacted several trees and came to rest inverted in a wooded area about 2 miles from DOV The inspector observed an approximate 150 foot debris path extending on a course about 190 degrees magnetic from the first tree branch separation to the main wreckage The right wingtip and right flap were observed at the beginning of the debris path The right wing and a section of vertical stabilator were located about 100 feet along the debris path with the remainder of the fuselage and engine at the end of the debris path The wings and fuselage were substantially damaged exhibited several tree strikes and there was no postcrash fire Both main fuel tanks were compromised The inspector observed no fuel in the right main fuel tank and approximately 1 2 g
39. 75 888 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING R680 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name ROSS A MILES Opr dba Aircraft Fire NONE Summary The pilot stated that he landed the airplane uneventfully on the grass runway and turned the airplane around at the end of the runway for a takeoff in the opposite direction The pilot reported that the wind was calm at this time After liftoff about 15 feet above the ground the pilot recognized that the airplane was not producing adequate power or accelerating as expected so he landed the airplane The airplane touched down near the departure end of runway went off the end of the runway and struck trees A witness stated that he saw the airplane take off but when it was about 20 to 30 feet above the ground the airplane leveled off and appeared to lose power On scene examination of the airplane did not reveal any anomalies that would account for the loss of engine power The weather conditions at the time of the accident were favorable for moderate carburetor icing at cruise power setting and serious icing at descent power setting It is not known if the pilot used carburetor heat before the accident however the carburetor heat control was found in the off position during postaccident examination Descent power settings yield a throttle angle similar to the low power settings used for taxi operations and that angle is conducive to the formation of carbu
40. A055 11 02 2013 0 Regis N6303E Loveland CO Acft Mk MdI CESSNA 172N Acft Dmg Rpt Status Prelim Prob Caus Pending Fatal 0 Serlnj 0 Opr Name Opr dba Aircraft Fire Printed January 15 2014 ann 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 Accident Rpt WPR12LA325 07 10 2012 930 MDT Regis N30753 Gooding ID Apt Gooding Municipal Airport GNG Acft Mk Mdl CESSNA 177 B Acft SN 17701443 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING 0360 AcftTT 4694 Fatal 0 Serlnj 1 Fit Conducted Under FAR 091 Opr Name PAMELA G WILLIAMS Opr dba Aircraft Fire NONE AW Cert STN Summary The pilot reported that the airplane did not initially encounter turbulence during the approach to the runway However after the airplane crossed the approach end of the runway and the pilot reduced the engine power for the landing flare the airplane s left wing was abruptly pushed upward The pilot was unable to maintain control the right main landing gear and the nose wheel touched down first and then the left main landing gear hit the runway hard The airplane exited the right side of the runway into weeds and proceeded into a small ditch The
41. ARFF unit of an Alert 2 At 2040 32 the airplane was at 3 000 feet msl and about 4 and 1 2 miles from CLL when the pilot reported that he had the airport in sight and would be landing on runway 16 At 2043 40 the airplane was at 600 feet msl when the pilot reported that he would not make the airport There were no further communications from the pilot and last radar retum was at 2043 46 WRECKAGE AND IMPACT INFORMATION The airplane wreckage was located in the parking lot of a large apartment complex about 2 miles north of CLL The area from the northwest through the southwest for a distance of over three miles was a congested urban area The initial impact crater was about 47 feet from the main wreckage final resting location Debris and ground scars led from the crater on a direction of 235 degrees to the main wreckage which came to rest about 45 feet from the nearest building of the apartment complex The nose of the airplane s upright fuselage was oriented to 358 degrees Aircraft debris and all portions of the airplane were found at the scene within a radius of about 100 feet from the final resting location There was impact damage to the leading edges of both wings and to the engine and forward fuselage Both wings exhibited aft accordion crushing along their Printed January 15 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 Resea
42. Action general Pilot C Narrative HISTORY OF FLIGHT On September 12 2012 about 1455 central daylight time a Piper PA 23 250 airplane N4842P impacted terrain following an in flight break up near Bullard Texas The commercial pilot was fatally injured and the airplane was substantially damaged The airplane was registered to X Aviation LLC Houston Texas and operated by a private individual under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight Visual meteorological conditions prevailed for the flight The flight originated from the David Wayne Hooks Memorial Airport KDWH Houston Texas about 1355 and was en route to the Tyler Pounds Regional Airport KTYR Tyler Texas According to eyewitness statements the airplane approached Lake Palestine near Bullard while flying several thousand feet above the ground The airplane was observed to make several turns pitched nose up and climbed The airplane then rolled to the right and headed toward the ground nose first Several witnesses observed airplane components floating down after the airplane All witnesses reported hearing loud engine noises throughout the event PERSONNEL INFORMATION The pilot age 51 held a commercial pilot certificate for airplane single engine land multi engine land and instrument airplane He was previously issued a flight instructor certificate for airplane single engine which expired on August 31 1983 On April 5 2012 the pilo
43. B78 The revision directed an accelerated compliance date of April 30 2013 All R44 helicopters overhauled at the factory as of July 21 2009 had the bladder kit installed automatically All new R44 Raven models produced beginning with serial number 2066 manufactured in October 2009 were equipped with the bladder tanks All new R44 Raven II models produced beginning with serial number 12891 manufactured in August 2009 were equipped with the bladder tanks Due to several similar low energy accidents with fatalities resulting from a post crash fire the Australian Civil Aviation Safety Authority CASA issued airworthiness directive AD R44 23 on April 29 2013 requiring installation of the bladders on all R44 helicopters by April 30 2013 Printed January 15 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 WPR13FA264 06 06 2013 1417 PDT Regis N915BW Los Angeles CA Apt N a Acft Mk Mdl ROBINSON HELICOPTER COMPANY R44 Acft SN 11428 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING I0 540 AE1A5 AcftTT 1546 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name SOUTHERN CALIFORNIA HELICOPTERS Opr dba Aircr
44. During that time the EGT was operating at an average temperature above 1 200 degrees F At an estimated time of 2032 about one hour and 20 minutes after the start of data the fuel flow decreased to about 13 gallons per hour and the EGT then reduced about 200 degrees Four minutes later at an estimated time of 2036 the EGT reduced another 200 degrees and within the next 30 seconds the EGT had cooled to below 300 degrees There were also corresponding significant reductions in other engine parameters Data from the EDM ended about one hour and 31 minutes after it began A Fujitsu Stylistic Tablet PC electronic flight bag EFB which had been removed from the wreckage was also examined at the NTSB vehicle recorder division Partial data from the hard disk drive was recovered however no accident related information was found in the recovered data Printed January 15 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 Accident Rpt ERA13CA420 09 13 2013 0 Regis N650DP Sussex NJ Acft Mk MdI ROLLADEN SCHNEIDER LS 6 Acft Dmg Rpt Status Prelim Prob Caus Pending Fatal 0 Serlnj 0 Opr Name Opr dba Aircraft Fire Printed January 15 2014 ann airsafety c
45. ETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS The failure of an engine connecting rod and the subsequent loss of oil pressure which resulted in a total loss of engine power Events 1 Enroute Loss of engine power total 2 Landing landing roll Collision with terr obj non CFIT Findings Cause Factor 1 Aircraft Aircraft power plant Engine reciprocating Recip eng cyl section Failure C 2 Aircraft Aircraft power plant Engine reciprocating Recip eng oil sys Failure C Narrative On December 19 2012 about 1700 central standard time a Piper L 18C airplane N3134G was substantially damaged during a forced landing near Graham Texas The private pilot and passenger were not injured The airplane was registered to and operated by a private individual 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 local flight originated from the Graham Municipal Airport KRPH Graham Texas about 1600 According to a statement provided by the pilot when returning to the airport he noted that the engine s oil pressure went to zero the roms began to reduce and the engine power decreased As the pilot maneuvered to perform a forced landing the engine seized and the propeller stopped The airplane landed hard bounced and nosed over coming to rest in the inverted position The airplane sustained substantial damag
46. METEOROLOGICAL INFORMATION The closest official weather observation station was CLL located 2 nautical miles south of the accident site The elevation of the weather observation station was 320 feet msl At 2053 the automated weather observing system at CLL reported wind from 170 degrees at 13 knots visibility of 10 miles clear of clouds temperature 29 degrees C dew point 21 degrees C with an altimeter setting of 29 71 inches of Mercury Data from the U S Naval Observatory showed that moonset occurred at 1648 sunset occurred at 2021 and the end of civil twilight occurred at 2048 COMMUNICATIONS AND RADAR The airplane was in cruise flight about 9 500 feet mean sea level msl and the pilot was receiving flight following from the Houston Air Route Traffic Control Center ARTCC At 2029 when the airplane was about 25 miles northeast from CLL the pilot advised the ARTCC controller that he wanted to make a fuel stop at CLL The ARTCC controller instructed the pilot to contact the tower controller at CLL The airplane then made a right tum of about 90 degrees and began descending toward CLL At 2035 30 the airplane was at 7 000 feet msl and about 11 miles from CLL when the pilot made his initial radio contact with the tower controller at CLL and he reported that he had to make a fuel stop At 2036 40 the pilot advised the controller that he was running out of fuel At 2037 the controller advised the aircraft rescue and firefighting
47. National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt WPR14CA067 12 09 2013 0 Regis N53MT Kalispell MT Acft Mk Md I BEECH 58P Acft Dmg Rpt Status Prelim Prob Caus Pending Fatal 0 Serlnj 0 Opr Name Opr dba Aircraft Fire Printed January 15 2014 ann airsafety com e product _ Copyright 1999 2012 Air Data Research Page 1 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 CEN12LA649 09 19 2012 910 CDT Regis N3629Q Tell City IN Apt Perry County Municpal Airport TEL Acft Mk MdI BEECHCRAFT A23 24 Acft SN MA 224 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING I0 360 A2B AcftTT 1615 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name ROBERT E THAYER Opr dba Aircraft Fire NONE Summary The pilot reported that he made a straight in approach to the runway after about a 10 minute flight He stated that there was no appreciable wind during the landing attempt for which he had fully extended the wing flaps He reported the airplane landed about one third of the way down the runway and that after touchdown he retracted the wing flaps and applied brake pressure to slow the airplane He stated that the airplane did not seem to decelerat
48. 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 ERA13LA111 01 13 2013 1845 EST Regis N4975S Dover DE Apt Dover Air Force Base DOV Acft Mk Mdl PIPER PA 28R 200 Acft SN 28R 35693 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING 10 360 AcftTT 5613 Fatal 1 Serlnj 0 Fit Conducted Under FAR 091 Opr Name TUREN CLIFFORD H Opr dba Aircraft Fire NONE Summary The pilot had planned a night instrument cross country flight of 3 hours 45 minutes with 5 hours 30 minutes of fuel onboard About 3 hours 20 minutes into the flight when the airplane was about 15 miles from the intended destination airport the pilot diverted after the airplane ahead of him performed a missed approach due to the low cloud ceiling The pilot diverted to a nearby airport where the wind was calm and the ceiling was overcast at 400 feet above ground level agl The airport was equipped with a precision instrument landing system ILS approach which the pilot did not attempt instead he attempted two GPS approaches to the opposite end of the runway During both GPS approaches the pilot performed missed approaches before the airplane reached the decision altitude of 306 feet agl Then about 4 hours 20 minutes into the flight the pilot diverted again this time to an airport th
49. The pilot stated that about 2 minutes prior to reaching the construction site he detected a vibration in the back of his seat as well as in the anti torque pedals This was followed immediately by a right yaw that was not correctable with pedal input The pilot opined that he attempted to maintain level flight then heard a metallic clunking sound behind him He then looked over his left shoulder and thought he observed the tail rotor slowing down He said he was still maintaining forward flight at about 70 knots and was maintaining his forward track by countering the yaw with left cyclic input The pilot stated that he picked out a residential area with a cul de sac street and elected to autorotate to the street He reported that he lowered collective rolled off the throttle to the idle detent and made a slight right turn toward the cul de sac maintaining about 55 knots during the autorotation The helicopter initially impacted the roof of a house and a brick wall that separated the house from the adjoining residence He said the helicopter came to rest in the backyard of the adjacent house in a slightly nose down upright attitude The pilot reported that the main and tail rotor blades were intact and that in his view this was a mechanical failure rather than a loss of tail rotor effectiveness event He also stated that during the descent the helicopter did not rotate about its vertical axis that it did not spin and that it was gusty with respect to the
50. Transportation Safety Board Aircraft Accident Incident Database Accident Rpt WPR14CA073 12 22 2013 0 Regis N185CY Carson City NV Acft Mk MdI CESSNA A185F Acft Dmg Rpt Status Prelim Prob Caus Pending Fatal 0 Serlnj 0 Opr Name Opr dba Aircraft Fire Printed January 15 2014 ann airsafety com e product _ 7 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 WPR13CA425 09 12 2013 1430 Acft Mk Mdl CESSNA M337B Eng Mk Mdl CONTINENTAL 10 360 Opr Name ARTEMIS INC Regis N87653 Spanish Fork UT Acft SN 337M0222 Acft Dmg SUBSTANTIAL AcftTT 5514 Fatal 0 Ser Inj Opr dba Apt Spanish Fork Airport U77 Rpt Status Factual Prob Caus Pending Fit Conducted Under FAR 091 Aircraft Fire NONE Narrative The pilot reported that on the day of the accident he elected to fly with a light and slightly uneven load of fuel to accommodate for the extra equipment and people onboard During the low altitude flight the pilot was not transferring fuel from the right wing fuel tanks to the left wing fuel tanks Subsequently the left wing fuel tanks ran empty and the forward engine lost power The pilot elected to land in a nearby com field During the landing
51. a limitation stated must wear corrective lenses The pilot reported on his most recent medical certificate application that he had accumulated 2 500 total flight hours No pilot or airplane logbooks could be located AIRCRAFT INFORMATION The two seat high wing fixed gear airplane serial number S N 12587 was manufactured in 1947 It was powered by a Lycoming O 290D2 engine serial number 6108 21 rated at 135 horse power The airplane was also equipped with a McCauley fixed pitch propeller model M74DM serial number 30761 METEOROLOGICAL INFORMATION A review of recorded data from the Bryce Canyon airport weather reporting facility that is about 40 miles west of the accident site revealed that the weather conditions at 1553 mountain standard time were winds calm clear visibility 10 statute miles temperature 1 degree Celsius dew point 7 degrees Celsius and a barometric setting of 30 47 inches of mercury WRECKAGE AND IMPACT INFORMATION Examination of the accident site revealed broken power poles and tangled high power lines about 30 feet east of Utah highway SR 12 The power lines were about 100 feet in height The first identified point of contact FIPC was one of the top power wires of a group of 5 power lines Two grounding wires smaller in diameter were on top and three wires carrying about 69 000 volts were about 8 feet lower There was a small discoloration on the top west side wire Printed January 15 2014 an airsafety
52. ad been convicted of driving while intoxicated in 1980 and 1981 During correspondence with the FAA regarding these events in 2006 the pilot reported social drinking two or three drinks with dinner and stated I do not use illegal substances After this process the pilot reported on subsequent applications for medical certification his previous convictions by checking yes to the relevant historical questions and then previously reported no change Also in 2006 the pilot reported using Advair to treat hay fever an inhaled prescription medication used to treat asthma that combines fluticasone propionate a steroid and salmeterol a long acting beta agonist and Prevacid for heartbum lansoprazole a proton pump inhibitor used to treat gastroesophageal reflux disease He was awarded his medical certificate without further investigation In 2008 he reported an injury to his Achilles tendon and Motrin ibuprofen a non steroidal anti inflammatory analgesic in addition to his previous medications In 2010 he reported the same medications and was awarded a third class medical certificate In August 2011 the FAA requested more information regarding the pilot s use of Advair The pilot supplied it with a letter from his physician who noted the Advair was being used to treat chronic obstructive pulmonary disease also known as emphysema with symptoms of bronchospasm and mentioned the pilot was trying to quit smoking No other information was off
53. aft Fire NONE Narrative HISTORY OF FLIGHT On June 6 2013 at 1417 Pacific daylight time a Robinson R44 II N915BW rolled over following a precautionary landing in Griffith Park Los Angeles Califomia The helicopter was registered to Southern Califomia Helicopters and operated as a personal flight by the pilot under the provisions of 14 Code of Federal Regulations Part 91 The flight instructor and private pilot sustained minor injuries the two passengers were not injured The helicopter sustained substantial damage during the accident sequence The local flight departed Brackett Field Airport La Veme Califomia about 1315 Visual meteorological conditions prevailed and no flight plan had been filed According to the flight instructor the primary purpose of the flight was to return the helicopter to Southern Califomia Helicopters Flight School at Long Beach Airport following maintenance at a facility at Redlands Municipal Airport Redlands California The private pilot rated passenger s experience was limited to the Robinson R22 helicopter so the flight instructor invited him along to gain familiarity with the operation of the R44 From Redlands they flew to Bracket Field to pick up the two passengers one of whom was related to the flight instructor His intension was to give the passengers a tour of the Los Angeles area before returning them to Bracket Field and the helicopter back to Long Beach The flight instructor serviced the helico
54. ahrenheit F dew point 64 degrees F and a barometric pressure of 30 03 inches of mercury WRECKAGE AND IMPACT INFORMATION The accident site was located on a road near a wooded residential area Damage to trees surrounding the accident site was consistent with a steep descent angle Airplane components were located in several directions from the accident site at distances up to one half mile The largest concentration was within a 40 yard radius of the main wreckage however wing components were scattered to the north and east of the accident site Ground impact signatures consisted of two impact craters one for left engine and one for the fuselage The main wreckage consisted of the fuselage empennage rudder elevators both engines and portions of both wings The odor of fuel was detected at the accident site The left wing was fragmented outboard of the left engine The left flap was found at the accident site along with a portion of the left aileron The left wing tip was found near a lake shore about 175 yards north of the accident site and the inboard portion of the aileron located about 500 yards north of the accident site The right wing was fragmented outboard of the right engine The right flap was found 40 yards east of the accident site along with the right aileron A large section of the right wing was recovered from a lake about 175 yards north of the accident site with the right wing tip was located 380 yard east of the accident site Bo
55. ailures or malfunctions that would have precluded normal operation The weather conditions at the time of the accident were conducive for serious icing at cruise power settings It is likely that the student pilot s delayed action in applying carburetor heat resulted in a partial loss of engine power due to carburetor icing Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS A partial loss of engine power after a descent to a lower altitude due to the student pilot s delayed action in applying carburetor heat while operating in conditions conducive to carburetor icing Events 1 Enroute cruise Loss of engine power partial 2 Enroute cruise Off field or emergency landing 3 Landing flare touchdown Collision with terr obj non CFIT 4 Landing flare touchdown Nose over nose down Findings Cause Factor 1 Environmental issues ConditionsAveather phenomena Temp humidity pressure Conducive to carburetor icing Contributed to outcome C 2 Personnel issues Action decision Action Delayed action Student pilot C Narrative On January 24 2013 about 1545 Pacific standard time a Cessna 150L N18690 experienced a partial loss of engine power during cruise flight near Matlock Washington The pilot subsequently made an off airport forced landing onto a road The student pilot was uninjured and the airplane sustained substantial damage to the right wing The airplane was registered to and o
56. all recounted that the airplane reached an altitude between 20 40 feet before the engine began to sputter and miss One witness described the airplane rocking from side to side at a slow airspeed prior to making a sharp left tum descending nose first and impacting the runway PERSONNEL INFORMATION The pilot owner held a private pilot certificate with ratings for airplane single engine land and instrument airplane The pilot s logbooks were not recovered and no determination of the pilot s total or recent flight experience could be made His most recent Federal Aviation Administration FAA third class medical certificate was issued in June 1978 The flight instructor held a commercial pilot certificate with ratings for airplane single and multiengine land and sea and instrument airplane and a flight instructor certificate with ratings for airplane single and multiengine and instrument airplane His most recent FAA second class medical certificate was issued in December 2011 Review of the flight instructor s logbooks indicated that he had accumulated approximately 940 hours of flight time at that date The flight instructor stated that prior to purchasing the accident airplane the pilot had not flown in over 30 years and was in need of a flight review to obtain currency He had completed seven or eight flights with the pilot in the weeks leading up to the accident Prior to that the pilot had flown around 5 hours with another flight
57. allon in the left main fuel tank The inspector did not observe any preimpact mechanical malfunctions with the airframe or engine MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot by the State of Delaware Office of the Chief Medical Examiner Wilmington Delaware on January 14 2013 Toxicological Printed January 15 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 testing was performed on the pilot by the FAA Bioaeronautical Science Research Laboratory Oklahoma City Oklahoma Review of the toxicological report revealed 10 ug ml ug g Acetaminophen detected in Urine 0 081 ug mL ug g Dihydrocodeine detected in Urine Dihydrocodeine NOT detected in Blood Heart Hydrocodone detected in Urine Hydrocodone NOT detected in Blood Heart 0 194 ug mL ug g Hydromorphone detected in Urine Hydromorphone NOT detected in Blood Heart Naproxen detected in Urine TESTS AND RESEARCH A handheld GPS receiver was recovered from the wreckage and data were successfully downloaded at the NTSB Vehicle Recorders Laboratory Washington DC for more information see GPS Device Factual Report in the public docket Review of a make and
58. and impact with the wall All 3 main rotor blades remained attached to the main rotor head and basically intact The green dot tail rotor blade was fractured at the outer end of the hub spline The blade was retained by the tail rotor strap pack and remained connected to the pitch change link There were fractures and distortion of the fiberglass airfoil inboard of the leading edge abrasion strip the spar was bent from impact forces on the outboard side and the aft portion of the tip cap was missing The blue dot tail rotor blade was observed intact from the root to the tipcap the tipcap was intact There was an area of damage to the airfoil near the inboard end of the abrasion strip The pitch change link remained attached and appeared straight The main rotor head MRH was intact and attached to the main drive shaft Printed January 15 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 The tail rotor hub TRH tail rotor assembly remained attached to the tail rotor gearbox TGB output shaft Both pitch change links were observed intact The swashplate rotated freely and moved in and out on the shaft when activated by the control rod and bellcrank The tai
59. anding gear collapse Findings Cause Factor 1 Aircraft Aircraft systems Landing gear system Gear extension and retract sys Failure C 2 Not determined Not determined general general Unknown Not determined C Narrative On October 2 2012 about 0900 eastem daylight time a Cessna 3101 N8025M operated by a private individual was substantially damaged while taxiing after landing at the Burlington International Airport BTV Burlington Vermont The private pilot and a passenger were not injured Visual meteorological conditions prevailed and no flight plan had been filed for the local personal flight that was conducted under the provisions of 14 Code of Federal Regulations Part 91 According to the pilot the airplane landed on runway 15 an 8 320 foot long asphalt and concrete runway without incident He taxied toward the end of the runway and was making a right tum onto taxiway C when the left landing gear began to collapse The left side of the airplane struck the ground which resulted in substantial damage to the left wing and left horizontal stabilizer Subsequent examination of the airplane by a Federal Aviation Administration FAA inspector revealed that the left main gear bellcrank pin separated from its bushing The pin was not located however the left main gear bellcrank and retraction link were removed and forwarded to the NTSB Materials Laboratory Washington D C for examination The airplane was manufactured in 1964 A
60. ane with safety and if the airplane is to give the long service it was designed to give It was also good practice before cleaning to check the interior for signs of leaking fittings and corrosion and to note any areas where further investigation is needed however to not make any repairs until the airplane was thoroughly cleaned to prevent contamination from toxic chemicals To facilitate cleaning and inspection of the interior the fuselage was equipped with removal panels Two large panels on each side of the fuselage were completely removable for access to the interior structure hopper and cockpit area A large door which was hinged at the top was also located just aft of the firewall on each side of the airplane for access to the forward fuselage components Smaller removal panels on the sides of the fuselage tailcone provided access to the control system cables and fuselage structure The engine cowling was also completely removable for access to the engine In general the entire fuselage structure could be exposed for cleaning and inspection The Owner s Manual also advised that in order to thoroughly clean the fuselage or hopper interior to first hose it down with water and then wash with warm soapy water A hose rinse should then follow to flush away the soapy water It further went on to say that when hosing down the interior it was best to remove the pilot s seat and precautions should be made to keep water away from the instrument panel ra
61. any and Lycoming examined the wreckage at Aircraft Recovery Service Littlerock California on November 27 2012 Detailed examination notes are in the public docket Airframe Investigators examined the elements of the surviving waming light bulbs on the annunciator panel All of the surviving elements were tight except for the clutch light which was stretched The main rotor gearbox chip detector was clean and the gearbox rotated freely by hand Rotational scuff marks were on the upper sheave there was rotational scoring on the cooling fan wheel The sprag clutch operated properly Flight controls Printed January 15 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 All rod ends were accounted for and all separations appeared to be thermal damage investigators noted no indication of preimpact failure of the flight control system Fuel System The main tank remained attached to the fuselage with the upper half consumed by fire The auxiliary fuel tank separated from the fuselage and was partially consumed by fire Fire consumed the gascolator housing the gascolator cup and screen were recovered and both were charred The fuel valve was in the
62. as manufactured in 1978 and was powered by two Lycoming TIO 540 350 hp engines Review of maintenance records showed that the airplane s most recent annual inspection was completed on September 9 2011 at 4 895 total hours of operation At the time of the accident the airplane had accumulated 4 912 total hours of operation According to the passenger the pilot had most recently serviced the airplane with fuel prior to flying from Gatlinburg Pigeon Forge Airport GKT Gatlinburg Tennessee to their home at FD44 Review of fueling records from a fixed based operator at GKT revealed that on October 19 2012 the airplane s inboard fuel tanks were filled to capacity with 32 gallons of aviation gasoline METEOROLOGICAL INFORMATION The weather conditions reported at LEE at 1453 located about 2 nautical miles south of the accident site included wind from 220 degrees at 11 knots gusting to 16 knots 10 statute miles visibility clear skies below 12 000 feet temperature 21 degrees Celsius C dew point 9 degrees C and an altimeter setting of 30 00 inches of mercury WRECKAGE AND IMPACT INFORMATION The initial impact point IIP was identified as a tree with broken limbs with various components of wreckage extending from that point on a heading of 135 degrees magnetic A ground scar approximately 6 feet wide by 100 feet long began about 50 feet from the IIP and was oriented along the wreckage path The fuselage came to rest upright oriented roughly
63. as overhauled at RAM Aircraft Waco Texas on September 13 2006 At the time of its most recent annual inspection the engine had accrued 966 3 hours since major overhaul SMOH The No 1 left engine was overhauled at RAM Aircraft Waco Texas on October 16 2009 At the time of its most recent annual inspection the engine had accrued 312 6 hours SMOH Oil samples were taken from each engine at the most recent annual inspection and sample testing was completed at Aviation Oil Analysis Phoenix Arizona on October 29 2012 According to the report for metals and contaminants content All values appear normal The owner of the maintenance facility where the annual inspection was completed held FAA commercial pilot flight instructor and airframe and powerplant certificates In an interview he said he performed a test flight with the accident pilot at the completion of the annual inspection Prior to takeoff on the test flight the propeller rom was matched on both engines on the ground but after takeoff the left engine showed 100 rpm above maximum when the right engine was at maximum Once the rpm was matched manually by the pilot the fuel flow on the left engine was about 1 5 to 2 0 gallons per hour below that of the right engine The fuel flow rate on the left engine was also below that prescribed in the engine maintenance guidance SID 97 3 The airplane was flown for 1 2 hours and during the flight cabin pressurization prop synchronization f
64. at approximately 1405 and was destined for Shelby County Municipal Airport EET Alabaster Alabama The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91 The pilot stated that the engine began to run rough while enroute at an altitude of 2 600 feet and he responded by activating the fuel boost pump The engine continued to run rough and shortly after experienced a total loss of power The pilot maneuvered the airplane toward a row of trees in the backyard of a residence and the airplane came to rest inverted resulting in substantial damage Examination of the airplane by a Federal Aviation Administration inspector who responded to the scene revealed that the airplane s fuel selector was set to the right wing tank position and that the right wing tank contained approximately 8 gallons of fuel A sample taken from the tank was absent of contamination Further examination of the engine was scheduled for a later date Printed January 15 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 Accident Rpt CEN13LA068 11 20 2012 1700 CST Regis N56226 San Antonio TX Apt Horizon 74R Acft Mk Mdl BOEING A75L3 Acft SN
65. at was not equipped with an ILS approach and had a reported overcast layer of clouds at 300 feet agl He performed a GPS approach to that airport during which he descended the airplane below the approach s published minimum descent altitude of 310 feel agl to about 250 feet agl before he performed a missed approach After the missed approach about 5 hours into the flight the pilot advised the air traffic controller that he was low on fuel and diverted to another airport with no ILS approach to attempt a very high frequency omnidirectional range VOR approach The pilot was in contact with air traffic control and could have declared an emergency and performed an ILS approach to a military airport that he overflew en route to the airport with the VOR approach however he did not The pilot was cleared for the VOR approach about 5 hours 5 minutes into the flight and declared an emergency 6 minutes later reporting fuel exhaustion Air traffic control personnel provided the pilot with radar vectors to the military airport he had overflown but the airplane impacted wooded terrain about 2 miles before it reached the runway at that airport Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS The pilot s failure to land the airplane at multiple airports that were equipped with adequate instrument approach procedures while operating in low instrument meteorological conditions and his delay in declaring a fuel
66. ation consistent with ground impact Main Rotor Gearbox The main rotor gearbox instrument panel along with the drive sheave and sprag clutch assembly were removed and examined at the facilities of Robinson Helicopter Inc RHC in the presence of the NTSB investigator in charge Both forward gearbox mounting lugs had separated from the casting during the accident sequence and remained attached to the airframe Their separation resulted in two 4 inch wide holes in the gearbox case and the expulsion of most of the gearbox oil onto the airframe The gearbox case was disassembled and the drive gears along with all bearings were examined with no defects noted About 5 teaspoons of blue colored oil was recovered from the sump and no debris or fragments were observed within the sump area or gear surfaces No anomalies were noted with the gearbox that would have precluded normal operation a full examination report is included within the public docket The main rotor gearbox chip detector appeared undamaged and free of debris Closer examination revealed the presence of fine fuzz particles in the area adjacent to the contact surfaces The electrical resistance of the chip detector was tested with an open circuit detected The Clutch MR Temp MR Chip Carbon Dioxide Starter On TR Chip Low Fuel Low rpm Fuel Filter Aux Fuel Pump and ALT lamps were removed and their filaments were examined All filaments were intact with no stretching observed
67. cation flight conducted under the provisions of Title 14 Code of Federal Regulations Part 137 According to the pilot he was spraying a cotton field near Lydia South Carolina when he completed a pass and at the end of the field pulled up to turn to the right During the climb he applied right rudder as usual but this time the right rudder pedal assembly broke off and went up against the back of the hopper tank The pilot then decided to return to a private airport where the airplane was based in Woodrow South Carolina as it was larger than the other spray strips in the area Upon arrival at the airport he flew over the top and used his cell phone to call and let personnel at the field know he would be landing without rudder control The landing was uneventful but during the landing roll the airplane began to turn left The pilot however had no way to correct for the left turn The airplane then exited the left side of the runway and entered a soybean field The right main landing gear then collapsed and the the right wing impacted the ground PERSONNEL INFORMATION According to Federal Aviation Administration FAA and pilot records the pilot held a commercial pilot certificate with a rating for airplane single engine land His most recent FAA second class medical certificate was issued on January 30 2013 He reported that he had accrued 2 249 total hours of flight experience of which 1 392 hours were in the accident airplane make and model
68. ccording to an FAA inspector at the time of the accident the airplane had been operated for about 3 675 total hours and 25 hours since its most recent annual inspection which was performed on August 8 2012 Metallurgical examination revealed that the bellcrank and retraction link were connected by a pin inserted through a clevis on the long arm of the bellcrank and a pivot hole on the retraction link One of the clevis tangs was bent outward and contained a small crack Both flange bushings were fractured in similar manners on the inside of the clevis and the liberated halves of the bushings displayed features consistent with overstress with no evidence of progressive cracking The edges of the inner bore of the pivot hole in the retraction link were locally deformed radially outward in one direction on each side of the link consistent with pin contact Additional information can be found in the Materials Laboratory Factual Report located in the public docket According to a representative from Cessna Aircraft Company Cessna was not aware of any previous failures or separations involving only the main landing gear bellcrank pin on Cessna 310 series airplanes Printed January 15 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
69. cft Dmg Rpt Status Prelim Prob Caus Pending Fatal 0 Serlnj 0 Opr Name Opr dba Aircraft Fire Printed January 15 2014 ann 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 WPR13FA095 01 19 2013 1501 MST Regis N2341N Boulder UT Apt Nia Acft Mk Mdl CESSNA 140 Acft SN 12587 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING 0 290D2 Fatal 2 Serlnj 0 Fit Conducted Under FAR 091 Opr Name BOWMAR PAUL Opr dba Aircraft Fire NONE Narrative HISTORY OF FLIGHT On January 19 2013 about 1501 mountain standard time a Cessna 140 N2341N sustained substantial damage when it struck power lines while maneuvering near Boulder Utah The airplane was registered and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91 The commercial pilot and passenger were fatally injured Visual meteorological conditions prevailed and no flight plan was filed for the personal flight The local flight departed from Escalante Municipal Airport 1L7 Escalante Utah at an undetermined time According to a local power company official the power line service between Boulder and Escalante were int
70. ch 24 1994 it was sold to an operator in Colorado and reinstated on the United States Civil Registry as N59JK Printed January 15 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 On July 16 1997 the airplane was modified by the installation of Aeronautical Testing Service Inc vortex generators on the wings and Split Flaps on the lower trailing edge of the inboard stub wing On April 2 2008 it was sold by the operator in Colorado and over the next year was operated by a succession of operators On September 14 2009 it was purchased by Hopkins Flying Service On April 7 2013 a Knisley Welding aftermarket modified exhaust system was installed On April 7 2013 the airplane received its most recent annual inspection At the time of the accident the airplane had accrued 5 393 2 total hours of operation METEOROLOGICAL INFORMATION The recorded weather at Shaw Air Force Base SSC Sumter South Carolina located 8 nautical miles southwest of the accident site at 1858 included winds 330 at 4 knots 10 miles visibility few clouds at 5 500 feet broken clouds at 10 000 feet temperature 31 degrees C dew point 19 degrees C and an altimeter setting of
71. ches of mercury The temperature and dewpoint were graphed on the Carburetor Icing Probability Chart provided in the Federal Aviation Administration Special Airworthiness Carburetor Icing Prevention Information Bulletin and the conditions were conducive for serious icing at cruise power Printed January 15 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 Accident Rpt WPR14FA078 12 26 2013 1821 PST Regis N251JM Fresno CA Apt Fresno Chandler Executive FCH Acft Mk Mdl CESSNA 172K P Acft SN 17259188 Acft Dmg DESTROYED Rpt Status Prelim Prob Caus Pending Eng Mk Mdl LYCOMING 0 320 SERIES Fatal 2 SerlInj 0 Fit Conducted Under FAR 091 Opr Name TIMOTHY FARMER Opr dba Aircraft Fire NONE Narrative On December 26 2013 about 1821 Pacific standard time a Cessna 172K N251JM was destroyed when it impacted terrain while maneuvering near the Fresno Chandler Executive Airport FCH Fresno California The airplane was registered to private individuals and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 The private pilot and his passenger sustained fatal injuries Dark night visual meteorological conditions prevailed and
72. cross the lower door seal Wire cutter blades were installed on the landing gear struts and in front of the cockpit windshield A steel deflector cable was installed between the top of the cockpit canopy and the top of the vertical tail The pilot restraint system consisted of seat belts and a double strap shoulder hamess The lower ends of the harness were permanently attached to the seatbelt According to Cessna Single Engine Service Bulletin SEB96 9 Service experience indicated that the seat belt and shoulder harness assembly could become worn frayed and or deteriorated To assist in maintaining optimum seat belt and shoulder harness performance and to minimize the potential for failure of the pilot restraint system the service bulletin required that the seat belt and shoulder harness assembly should be inspected and replaced at specific intervals This service bulletin required that some seat belt and shoulder harnesses be replaced before flight and some within 100 hours or six months however ultimately all the existing seat belt and shoulder harness restraint systems should have been replaced within one year Printed January 15 2014 an airsafety com e product Copyright 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 Accid
73. d that the helicopter continued to lose altitude and it became apparent that it was either going to land or crash The witness added that after arriving at the accident site the engine continued to run for some time He added that the tail rotor blades were spinning rapidly PERSONNEL INFORMATION The pilot age 40 possessed a commercial pilot certificate for rotorcraft helicopter and ratings for instrument helicopter and helicopter instructor The pilot completed his most recent flight review on March 29 2012 He was issued a second class Federal Aviation Administration FAA airman medical certificate without waivers or limitations dated December 31 2011 The pilot reported a total flight time of 1 460 hours all in helicopters with 1 030 hours in make and model 1 410 hours as pilot in command and 980 hours as pilot in command in make and model Additionally the pilot reported having given 950 hours of dual instruction with 800 hours of dual instruction given in the accident make and model helicopter The pilot revealed that he had flown a total of 90 hours 30 hours and 1 hour in the preceding 90 days 30 days and 24 hours respectively AIRCRAFT INFORMATION The accident helicopter was a Hughes Model 269C serial number 0694C manufactured in 1978 Its most current airworthiness certificate was issued on April 1 2009 At the time of the accident the helicopter had accumulated about 1 584 hours total airframe time with a Hobbs Meter time o
74. dent Rpt ERA13LA054B 11 10 2012 1055 EST Regis N1370V Williamson GA Apt Peach State GA2 Acft Mk Mdl BOEING E75 Acft SN 75 5185 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl CONTINENTAL W670 6N AcftTT 928 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name JAMES G RATLIFF Opr dba Aircraft Fire NONE Summary The pilot of an amateur built RV 12 intended to land at the non towered airport while a Boeing E75 Stearman which was the lead airplane in a flight of three Stearman airplanes planned to fly over the airport at traffic pattern altitude as part of a fly in event being held at the airport The pilot of the RV 12 overflew the airport at an altitude of about 600 feet above the traffic pattern altitude and entered a right downwind leg of the traffic pattern for a landing on runway 13 Both pilots stated that they communicated their respective positions and intentions over the airport s common traffic advisory frequency In addition they stated that they were looking for each other when the two airplanes collided The pilots were subsequently able to land their respective airplanes without further incident Examination of the airplanes revealed substantial damage to the lower left side of the RV 12 s fuselage aft of the engine cowling and to the Stearman s rudder The damage was consistent with the RV 12 flying on a northwest heading and the Stearman flying on a northerly heading at the time of the collision Visual mete
75. dered 0 0130 to 0 0990 ug mL and it carries the following FDA warning may impair mental and or physical ability required for the performance of potentially hazardous tasks e g driving operating heavy machinery Finally toxicology testing revealed the pilot s use of marijuana including identifying the parent drug tetrahydrocannabinadl in liver 0 1628 ug ml lung 0 1921 ug ml and heart blood 0 0139 ug ml and the primary metabolite tetrahydrocannabinol carboxylic acid in liver 0 3417 ug ml lung 0 0454 ug ml and heart blood 0 0239 ug ml TESTS AND RESEARCH According to the Piper Navajo Chieftain Service Manual the float type resistance fuel senders could be tested by measuring the resistance at the float s full and empty positions The published electrical resistance limits at the empty and full positions for the inboard fuel tanks was between 0 0 to 0 5 ohms while the resistance at the full position was between 48 and 52 ohms The left inboard fuel tank fuel sender displayed a resistance of 0 38 ohms in the empty position and 59 ohms in the full position while the right inboard fuel tank sender displayed a resistance of 0 9 ohms in the empty position and 40 5 ohms in the full position The published resistance limits at the empty and full positions for outboard fuel tanks was between 0 0 to 0 5 ohms while the resistance at the full position was between 38 and 42 ohms The outboard fuel tank fuel sender displayed a resistance of
76. determined Not determined general general Unknown Not determined Se OS NS Narrative HISTORY OF FLIGHT On December 8 2012 at 1334 eastern standard time a Cessna 421C N297DB operated by a private individual was destroyed when it collided with trees and terrain following a loss of control after takeoff from North Palm Beach County Airpark LNA Lantana Florida The commercial pilot was fatally injured Visual meteorological conditions prevailed and no flight plan was filed for the personal flight which was conducted under the provisions of Title 14 Code of Federal Printed January 15 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 Regulations Part 91 The pilot took delivery of the airplane from a maintenance facility that had just completed an annual inspection and repainting of the airplane According to the owner of the facility who was a certificated pilot and an airframe and powerplant mechanic the pilot completed the preflight inspection and the airplane was towed outside The pilot started the airplane but then shutdown to resolve an altemator charging light Afterwards the pilot stated that he planned to fly to Okeechobee Florida comple
77. dio heater outlets and map compartment and that a Printed January 15 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 23 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 protective waterproof covering for these items was recommended Service Manual and Illustrated Parts Catalog Review of the Cessna 188 and 188T Service Manual and Cessna Model 188 Series Illustrated Parts Catalog IPC revealed that the manufacturer had published inspection criteria for the airplane based on operating usage and operating environment that provided mandatory time and inspection time intervals for components and airplane structures as well as information on disassembly overhaul and parts breakdowns The manufacturer had also enacted a Corrosion Prevention and Control Program CPCP to help prevent or control corrosion in the airplane s primary structure so that it did not cause a risk to continued airworthiness as the airplane aged Further review of the Service Manual also revealed that the manufacturer had included expanded maintenance inspection items that were to be examined after the first 100 hours of operation The inspection was then to be repeated every 600 hours of operation or 12 months whichever occurred first af
78. e The 269A5430 driving spline moved aft in the TRDS far enough to disengage from the internal splines of the TRDS The engine was intact and observed to have sustained minimal damage due to impact forces The engine mounts and engine basket tubing remained attached however some visible damage was observed The lower section of the engine inclusive of the intake and exhaust manifolds fuel servo control throttle linkage impeller assembly impeller shroud and the Bendix gear and housing experienced minimal visual damage as a result of impact forces to the undercarriage of the helicopter A Lycoming Engines representative was present during the examination Only an external examination of the engine was performed Due to local law enforcement personnel reporting that the engine remained running at the accident and secured only after first responders had arrived a more detailed examination of the engine was not performed by the Lycoming representative TESTS AND RESEARCH Examination of components parts Under the supervision of the IIC the following components were shipped to the NTSB Materials Laboratory in Washington D C for examination and analysis by a materials research engineer the main transmission pinion the aft pinion nut a section of the tail rotor drive shaft the driving spline the phenolic plug and the forward bump stop Driving Spline and Section of Tail Rotor Drive Shaft The engineer reported fretting wear scars and mate
79. e the flight departed for Prescott The pilot stated that the airplane subsequently ran out of fuel as they approached the Parker very high frequency omnidirectional radio range transmitter VOR about 200 miles west of Santa Ana He performed a forced landing into a rocky outcropping about 13 miles northeast of Avi Suquilla Airport TESTS AND RESEARCH Recovery personnel drained about 6 ounces of fuel from the fuel tanks during recovery of the airplane and a subsequent examination of the airframe and Printed January 15 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 engine by an FAA inspector did not reveal any fuel leaks The airplane was equipped with both an Avidyne Entegra Primary PFD and Multifunction MFD Flight Display and two Garmin GNS 430 GPS Navigation Communication transceivers The Avidyne units were capable of recording the airplane s GPS position as well as engine and fuel flow parameters The units were sent to the NTSB Office of Research and Engineering for data extraction The data for both flights had been recorded The flight from Santa Monica to Santa Ana lasted about 23 minutes and included an initial climb from about sea leve
80. e Airport ILG Wilmington Delaware From 1300 to 1600 the forecast weather included visibility 2 miles in mist and an overcast ceiling at 400 feet however from 1600 to 1900 the forecast weather at ILG included visibility 6 miles in mist and a broken ceiling at 1 200 feet From 1100 to 1700 the forecast weather at BWI included visibility 2 miles in light drizzle and mist and a broken ceiling at 300 feet From 1700 to 2200 the forecast weather at BWI included visibility greater than 6 miles and a broken ceiling at 3 000 feet The recorded weather at SBY at 1629 was wind from 150 degrees at 8 knots visibility 8 miles overcast ceiling at 400 feet temperature 13 degrees C dew point 11 degrees C altimeter 30 06 inches Hg The recorded weather at SBY at 1654 included visibility 7 miles and an overcast ceiling at 400 feet The recorded weather at BWI at 1654 included visibility 1 2 mile in light drizzle and fog and an overcast ceiling at 200 feet The recorded weather at GED at 1654 was wind from 190 degrees at 7 knots visibility 10 miles overcast ceiling at 700 feet temperature 13 degrees C dew point 11 degrees C altimeter 30 07 inches Hg The recorded weather at GED at 1751 included visibility 6 miles in mist and overcast ceiling at 300 feet The recorded weather at DOV at 1842 was wind from 330 degrees at 3 knots visibility 4 miles in mist overcast ceiling at 400 feet temperature 8 degrees dew point 8 degrees altimeter 30 0
81. e normally during the landing roll likely because of the downslope of the runway so he elected to abort the landing The pilot estimated that he increased engine power for the aborted landing as the airplane passed midfield and the airplane accelerated to liftoff speed while still on the runway however it did not clear a 10 foot high airport security fence that was located about 340 feet from the departure end of the runway The pilot reported no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation A postaccident examination of the runway overrun area showed tire tracks consistent with the tire width of the accident airplane The postaccident examination did not reveal any anomalies with the airplane brake system that would have prevented normal operation Landing performance calculations indicated that the airplane should have been able to stop within 1 000 feet of touchdown Considering that the runway was 4 400 feet long and given the existing calm wind and dry runway conditions the pilot should have been able to stop the airplane on the available runway thus it is likely that the airplane landed long on the runway Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS The pilot s improper touchdown point during landing and the resultant runway excursion during the aborted landing Events 1 Landing flare touchdown Landing area overshoot
82. e of about 100 feet above the ground At that point the flight instructor noted an audible loss of rpm that was confirmed by the tachometer The airplane began to descend the pilot applied carburetor heat and the flight instructor assumed control of the airplane With insufficient runway remaining on which to land and obstacles at the end of the runway that made a straight ahead off airport landing hazardous the flight instructor attempted to maneuver toward the ramp area adjacent to the runway The airplane subsequently stalled impacted the runway in a nose down attitude and came to rest inverted Postaccident examination of the airplane revealed no evidence of any preimpact mechanical failures or anomalies that would have precluded normal operation The flight instructor stated that the takeoff was initiated with the carburetor heat off despite a placard in the airplane requiring the use of carburetor heat during takeoff and landing Although the weather conditions at the time of takeoff were conducive to the formation of carburetor ice at glide and cruise power at the time of the accident it was not possible to determine whether carburetor ice was a factor in the accident Weight and balance calculations revealed that the airplane was loaded about 68 pounds over its maximum allowable gross weight and calculated density altitude at the airport about the time of the accident was more than 2 000 feet Despite these factors both of which would have advers
83. e to the wings and rudder An examination of the engine revealed a broken connecting rod and damage to the engine case The reason for the failure of the connecting rod could not be determined Printed January 15 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 Accident Rpt WPR14CA064 12 08 2013 0 Regis N6913 San Carlos CA Acft Mk Mdl PIPER PA 16 Acft Dmg Rpt Status Prelim Prob Caus Pending Fatal 0 Serlnj 0 Opr Name Opr dba Aircraft Fire Printed January 15 2014 ann 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 Rpt CEN12FA628 09 12 2012 1455 CDT Regis N4842P Bullard TX Apt N a Acft Mk Mdl PIPER PA 23 250 Acft SN 27 413 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING 0 540 SERIES AcftTT 6085 Fatal 1 Serlnj 0 Fit Conducted Under FAR 091 Opr Name INDIVIDUAL Opr dba Aircraft Fire NONE Summary
84. eficiencies such as inclusions voids or pits were found at the crack initiation site According to the helicopter s maintenance records the pinion had been in service for 1 584 4 hours and on the day before the accident a 100 hour inspection had been performed in accordance with the helicopter manufacturer s instructions These instructions included a procedure for checking the torque of the aft pinion nut and a co owner of the helicopter reported that he observed the mechanic perform the torque check It is likely that the fatigue crack was not large enough to be detected during the inspection and then propagated to the point of failure during the accident flight Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS A loss of tail rotor drive due to a fatigue failure of the main transmission pinion which resulted in a loss of directional control during cruise flight Events 1 Enroute cruise Sys Comp malfffail non power 2 Maneuvering Loss of control in flight 3 Autorotation Collision with terr obj non CFIT Findings Cause Factor 1 Aircraft Aircraft propeller rotor Main rotor drive general Not specified C 2 Aircraft Aircraft oper perf capability Performance control parameters Directional control Attain maintain not possible C 3 Personnel issues Task performance Use of equip info Aircraft control Pilot C Narrative HISTORY OF FLIGHT On May 2 2012 about 1140
85. el from that tank However about 15 minutes after departure the pilot advised air traffic control that the airplane was critically low on fuel About 5 minutes later both engines lost total power and the airplane descended into trees and terrain Examination of the airframe and engines after the accident confirmed that all of the airplane s fuel tanks were essentially empty and that the trace amounts of fuel recovered were absent of contamination Based on the autopsy and toxicology results the pilot had emphysema hypertension dilated cardiomyopathy and severe coronary artery disease however given that the passenger did not report any signs of acute incapacitation and that the pilot did not communicate any medical issues to air traffic control it does not appear that these conditions affected his performance on the day of the accident The pilot did not report any chronically painful conditions to the FAA in his most recent medical certificate applications however postaccident toxicology tests indicated that the pilot was taking several pain medications diclofenac gabapentin and oxycodone and one illegal substance marijuana Based on the medications Food and Drug Administration wamings gabapentin and oxycodone may be individually impairing and sedating their combined effect may be additive The effects of the underlying conditions that necessitated the medication could not be determined It is impossible to determine from the available
86. ely affected both the distance required for takeoff and the airplane s rate of climb once airbome the pilots elected to conduct an intersection takeoff which reduced the available runway takeoff distance by nearly 20 and also reduced the diversionary options available in the event of a loss of engine power Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS The flight instructor s and the pilot s failure to maintain airspeed after a partial loss of engine power after takeoff for reasons that could not be determined during postaccident examination which resulted in an aerodynamic stall and loss of airplane control Contributing to the accident were the pilots decisions to operate the airplane above its maximum allowable gross weight and to perform an intersection takeoff Events 1 Initial climb Loss of engine power partial 2 Initial climb Aerodynamic stall spin 3 Initial climb Loss of control in flight 4 Uncontrolled descent Collision with terr obj non CFIT Findings Cause Factor 1 Aircraft Aircraft oper perf capability Performance control parameters general Not attained maintained C 2 Personnel issues Action decision Action Lack of action Instructor check pilot C 3 Personnel issues Action decision Info processing decision Decision making judgment Flight crew F 4 Aircraft Aircraft oper perf capability Aircraft capability Maximum weight Capability exceeded
87. ent Incident Database For airplanes equipped with a four point seat belt and shoulder harness restraint system such as the accident airplane an initial inspection was required and then an operational inspection was to be accomplished within the next 50 hours of operation or 3 months whichever occurred first Repetitive inspections were then required which included an operational inspection 50 hours of operation after the initial inspection or a seat belt and shoulder harness replacement The replacement of the seat belt and shoulder harness with a five point restraint system was then required before the next flight for harnesses that failed an operational inspection or within the next 12 months for seat belt and shoulder harnesses that passed the initial operational inspection Examination of the seat belts and double strap shoulder hamess in the airplane revealed however that they were manufactured in 1972 They displayed areas of broken stitching wear fading and furthermore graying which indicated that they were also deteriorating due to exposure to sunlight and ultra violet rays TESTS AND RESEARCH Rudder Brakes and Tail Wheel The primary flight control surfaces ailerons elevator and rudder were controlled by a conventional control stick and rudder pedal arrangement The rudder system consisted of individual rudder pedal assemblies with return springs rudder rudder bellcrank cables and pulleys The hydraulic brakes on the mai
88. ent Rpt CEN12LA514 08 03 2012 919 CDT Regis N2008S Holcomb KS Apt Private Airstrip PVT Acft Mk Mdl WEATHERLY AVIATION CO INC 620B Acft SN 1559 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl P amp W R 985 SERIES AcftTT 3353 Fatal 0 Serin 0 Fit Conducted Under FAR 137 Opr Name FARMERS AVIATION INC Opr dba Aircraft Fire NONE Summary The pilot noted that the engine rpm during the takeoff was about 30 rpm lower than normal but was still within the normal operating range He reported that the airplane s engine then lost partial power as it climbed through about 50 feet above ground level after takeoff After the airplane lost power the pilot attempted to drop the chemical load to remain airborne however the airplane impacted an open field about 1 mile from the departure airstrip Subsequent examinations of the airplane s engine and its systems did not reveal any anomalies that would explain the loss of engine power The weather conditions at the time of the accident were conducive to carburetor icing at glide and cruise power and were within the range of susceptibility for serious icing at glide power Glide power settings yield a throttle angle similar to low power settings used for taxi operations therefore it is likely that the airplane s carburetor accumulated ice after engine run up and during taxi which was not detected by the pilot The pilot did not mention using carburetor heat during the pretakeoff engine run up or du
89. er and the flow did not decrease until the valve was turned much closer to the off position The throttle control was found at idle the mixture control in the full rich position and the carburetor heat control in the off position The temperature an dew point recorded at a station about 3 miles from the accident site were 24 degrees Celsius and 14 degrees Celsius respectively According to a carburetor icing probability chart the recorded temperature and dew point were in the range of susceptibility for moderate carburetor icing at Printed January 15 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 5 National Transportation Safety Board Aircraft Accident Incident Database cruise power setting and serious icing at descent power setting The pilot s statement did not mention if carburetor heat was used during the previous landing or during the accident takeoff Printed January 15 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 Acci
90. er cleared the flight direct to SBY and the airplane reversed direction to south about 15 miles south of EVY at 1650 The pilot then attempted two GPS approaches to runway 14 at SBY and performed a missed approach both times The descent altitude for the approach utilizing localizer performance with vertical guidance LPV was 355 feet msl or 306 feet above ground level agl however the pilot discontinued the first approach at a GPS altitude of 581 feet when the airplane was aligned with the runway about 1 7 miles from the runway During the second approach the airplane descended to 928 feet GPS altitude while aligned with the runway but then veered right and continued to descend to 529 feet before performing another missed approach At that time the pilot advised air traffic control that his GPS was not working right and he was going to try it again The wind was reported as calm and runway 32 6 400 feet long at SBY was equipped with an instrument landing system ILS approach however the pilot did not request that approach and did not attempt another GPS approach to SBY After the second missed approach the pilot requested to divert to Sussex Country Airport GED Georgetown Delaware at 1753 At that time the controller reported the last recorded ceiling at GED which was 700 feet overcast At 1801 when the pilot was cleared for the GPS runway 22 approach to GED the controller advised that the updated weather recording which was 7 minute
91. er made two rotations when a portion of the right wing separated and fell to the ground The glider continued the spin into the ground The tow pilot stated that he towed the glider to an altitude of 2 800 feet above ground level AGL and then it released He flew the tow plane back to the airport and landed about 5 minutes later He went to join the other witnesses to watch the glider soar After about 5 minutes the glider was to the north at about 2 000 feet AGL in a nose low attitude and appeared to be in a spin The right wing appeared to be broken but not completely separated During the spin about half of the right wing separated The glider made about 4 rotations prior to impacting terrain PERSONNEL INFORMATION The pilot age 78 held a commercial pilot certificate for airplane single engine land airplane multiengine land and glider issued on March 3 2010 He was also issued a second class medical certificate on April 26 2012 with limitations of having glasses available for near vision The pilot s logbook has not recovered for examination On the pilot s April 26 2012 application for the medical certificate he reported 12 695 total flight hours and 120 flight hours in the past 6 months The passenger age 14 was seated in the rear seat AIRCRAFT INFORMATION The two seat forward swept wing glider was manufactured in 1965 by Alexander Schleicher in Germany A standard normal airworthiness certificate was issued for the glider on May 1
92. ered The FAA subsequently provided the pilot with a special issuance medical certificate with the limitation not valid for any class after 5 31 2012 The pilot was not examined and had not obtained any subsequent medical certificates following the expiration of the special issuance medical certificate Post Accident Findings and Toxicology An autopsy was performed on the pilot by the Medical Examiner District 5 Leesburg Florida According to the autopsy report the cause of death was multiple blunt force injuries Significant natural disease was identified particularly in the heart which was markedly enlarged and weighed 750 grams normal for a man of his weight is between 305 and 531 grams 1 In addition the coronary arteries displayed severe atherosclerosis with greater than 95 narrowing of the proximal left anterior descending coronary artery Both ventricles were dilated but the walls were of normal thickness No histology of the cardiac tissue was performed The autopsy also noted severe pulmonary anthracosis and emphysema with scarring The FAA s Civil Aerospace Medical Institute performed forensic toxicological testing on specimens from the pilot The testing identified a number of Printed January 15 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 airsa
93. errupted at 1501 when an automatic breaker tripped He immediately responded to the power outage and noticed the power lines near mile marker 78 on Utah State Route SR 12 were tangled He stated that a portion of the airplane s wing was lying on the highway and was necessary to move it off the road He further stated that two power line poles were damaged and the attached power lines were lying near the ground Power company personnel were able to estimate the height of the power lines at the approximate point of impact to be about 100 feet A witness located on the west side of Utah SR 12 near the accident site reported that he observed the airplane fly over his position on an easterly heading He stated that the engine sounded loud and startled him He estimated the airplane to be about 200 to 300 feet above ground level agl and shortly afterwards he observed the airplane strike the power lines He further stated that the airplane s engine sounded loud until it struck the power lines Another witness observed the airplane s engine stop and sparks coming from the power lines after impact Several local residents of Escalante witnessed the pilot flying at low altitude on previous flights PERSONNEL INFORMATION The pilot age 56 held a commercial pilot certificate He had a commercial and instructor rating for gliders and private privileges for airplane single engine land A third class airman medical certificate was issued on January 17 2011 with
94. f 899 hours The most recent periodic 100 hour annual inspection was performed on May 1 2012 The previous periodic inspection encompassed 25 50 100 200 400 hour inspections which were completed on March 29 2012 at a total airframe time of 1 481 4 hours with a Hobbs Meter time of 796 4 hours The maintenance records revealed that the last annual inspection was completed on May 6 2011 at a total airframe time of 981 6 hours It was revealed during the investigation that during the periodic inspection conducted on May 1 2012 which was the day prior to the accident that a 25 50 100 Printed January 15 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 hour inspection had been performed in accordance with the manufacturer s Helicopter Maintenance Instructions HMI which included the procedure for checking the proper torque of the aft pinion nut The co owner of Canyon State Aero reported to the IIC that he had personally observed the mechanic performed the torque check of the aft pinion nut The aircraft maintenance logbook revealed no entry for this specific check nor was one required under Federal Aviation Regulation FAR Part 91 Additionally and while checkl
95. fered a recurrence of major depression and required escalating doses of fluoxetine and the addition of aripiprazole At the time of the fatal crash the medical records showed the pilot s depression had improved but not resolved and his mediations were still being adjusted A review of the FAA airman medical certification file revealed the pilot s first medical certificate was issued in 1978 and was re issued without limitations or deferment periodically until 1989 the pilot reported a DUI conviction and both a hospitalization and medication use for depression His application was deferred and multiple documents were requested by the FAA In November 1990 the pilot s application for a medical certification was denied In 1992 the pilot reapplied and after supplying documentation of resolution of his major depression and reporting that he was off all medications he was issued a third class certificate This contained a request that when he reapplied for a medical certificate he include a current status report from the treating physician The pilot failed to provide the status report on his re examination in 1994 and his certificate was deferred By May 1995 the necessary report demonstrating stability had been provided and the medical certificate was issued The pilot next applied for a medical certificate in 2008 and was issued a third class certificate after reporting he was taking Zocor and that all of his previous issues were previously reported
96. fety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database medications in liver tissue and urine samples including valsartan and metoprolol both blood pressure medications marketed under the trade names Diovan and Lopressor respectively and gabapentin a medication whose mechanism is not known used to treat chronic or neuropathic pain or to help prevent seizures and marketed under the trade name Neurontin Gabapentin carries the following FDA waming Warning may cause dizziness somnolence and other symptoms and signs of CNS depression Accordingly they should be advised neither to drive a car nor to operate other complex machinery until they have gained sufficient experience on Neurontin to gauge whether or not it affects their mental and or motor performance adversely The urine samples also tested positive for diclofenac a prescription non steroidal anti inflammatory and analgesic marketed under the trade name Voltaren and oxymetolazine an over the counter intranasal medication used to treat runny nose In addition testing found 0 043 ug mL of oxycodone in heart blood and 0 767 ug mL in urine Oxycodone s primary metabolite oxymorphone was identified in urine 2 328 ug mL Oxycodone is a semi synthetic narcotic pain medication prescribed as a schedule II controlled substance it is the narcotic portion of the medication marketed under the trade name Percocet Oxycodone s therapeutic dose is consi
97. he fuselage but still attached by their respective flight control cables The elevator trim tab cable was severed Flight control continuity with the attached control cables was established to the cockpit controls The engine remained partially attached to the fuselage and several mounts were found fractured All engine accessories remained attached to the engine via their respective mounts with the exception of the carburetor which was separated A postaccident examination of the airframe and engine revealed no evidence of mechanical anomaly or failures that would have precluded normal operation MEDICAL AND PATHOLOGICAL INFORMATION The Utah county coroner conducted an autopsy on the pilot on January 20 2013 The medical examiner determined that the cause of death was blunt force injuries The FAA s Civil Aeromedical Institute CAMI in Oklahoma City Oklahoma performed toxicology tests on the pilot According to CAMI s report carbon monoxide cyanide volatiles and drugs were tested and had negative results TESTS AND RESEARCH A Lowrance Airmap 1000 portable navigation device was located at the accident site and sent to the National Transportation Safety Board Vehicle Recorder Laboratory for examination No data relating to the accident flight was found on this device ADDITIONAL INFORMATION An examination of the recovered airframe and engine was conducted on February 6 2013 at the facilities of Air Transport in Phoenix Arizona N
98. hickness at the top of the rudder pedal arm appeared to be full thickness with measurements of 0 054 inch 0 053 inch 0 056 inch and 0 055 inch measured at 90 degree intervals around the circumference measurements of the tube wall thickness at the point of the fracture were only 0 030 inch at the thickest point and 0 013 at the thinnest point Maintenance Records Review of the maintenance records revealed no record of when the right rudder pedal had been modified by addition of the fender washer and bolt nut assembly on the outboard side or of the bronze bushing assembly on the inboard side Nor was any record discovered as to when the rudder pedal arms had Printed January 15 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 the silicon sealant plugs added to them Furthermore no record of Supplemental Inspection Number 27 20 01 being accomplished was discovered Printed January 15 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 T
99. homa The specimens provided were negative for ethanol and drugs TESTS AND RESEARCH A layout of the airplane s wings and fuselage was conducted Both wings displayed near symmetric damage and deformation with signatures that both wings failed in overload with positive wing loading Examination of the empennage did not reveal any signatures of over travel or flutter Printed January 15 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 ERA14LA085 01 04 2014 1520EST Regis N9409J Bronx NY Apt Nia Acft Mk Mdl PIPER PA 28 180 Acft SN 28 3516 Acft Dmg SUBSTANTIAL Rpt Status Prelim Prob Caus Pending Eng Mk Mdl LYCOMING 0 360 A3A AcftTT 2516 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name SCHWARTZ MICHAEL Opr dba Aircraft Fire NONE Narrative On January 4 2014 about 1520 eastern standard time a Piper PA 28 180 N9409J was substantially damaged during a forced landing on an expressway in Bronx New York The private pilot and two passengers were not injured The airplane was registered to and operated by a private individual under the provisions of 14 Code of Federal Regulations CFR Part 91 as a personal flight Visual meteorol
100. ht 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 reveal any anomalies with the airplane brake system that would have prevented normal operation The closest weather observing station was located at the Huntingburg Airport HNB about 21 miles northwest of the accident site At 0915 the HNB automated surface observing system reported wind 160 degrees at 4 knots visibility 10 miles sky clear temperature 14 degrees Celsius dew point 7 degrees Celsius and an altimeter setting of 30 19 inches of mercury According to the Pilot s Operating Handbook POH for the Beechcraft model A23 24 airplane the landing ground roll at maximum gross weight on a paved level and dry runway with no headwind and using maximum braking is about 750 feet The POH does not provide landing distances for runways that have a downslope however Civil Aviation Authority CAA research indicated that ground roll increases 10 percent with a 2 percent downslope According to available runway survey data runway 31 at KTEL has a 1 3 percent downslope Therefore the landing roll distance without a headwind and using maximum braking would be expected to be less than 825 feet CAA research also indicated that ground roll increases 20 pe
101. i California The owner pilot operated the airplane under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight The pilot and one passenger were not injured The airplane sustained substantial damage to its wings and fuselage when it struck a berm and nosed over during the landing roll out The airplane had departed from the Kingdon Airpark 020 Lodi about 1030 and was destined for the Modesto City County Airport Harry Sham Field MOD Modesto Califomia Visual meteorological conditions prevailed for the local area flight and no flight plan had been filed According to a responding deputy from the San Joaquin Sheriffs Department the pilot reported that shortly after takeoff the engine started to sputter He turned back to the departure airport and attempted to restart the engine After switching fuel tanks the engine regained full power then quit completely The pilot made a forced landing to an open field which appeared to be free of obstructions However during the landing rollout the airplane struck a berm and nosed over coming to rest inverted Printed January 15 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 Accid
102. icopter was a Robinson R44 II serial number 12634 A review of the maintenance logbooks revealed that it had a total airframe time of 133 4 hours at the last annual inspection on February 2 2012 The engine was a Lycoming 10 540 AE1A5 serial number L33351 48E Total time recorded on the engine at the last annual inspection was 133 4 hours Examination of the maintenance records revealed no unresolved maintenance discrepancies against the helicopter prior to departure METEOROLOGICAL CONDITIONS Printed January 15 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 An aviation routine weather report METAR for Corona KAJO elevation 533 feet was issued at 2256 PDT It stated wind calm visibility 2 1 2 miles mist sky 300 feet overcast temperature 12 54 degrees Celsius Fahrenheit altimeter 29 98 inches of mercury WRECKAGE AND IMPACT INFORMATION Investigators examined the wreckage at the accident scene on November 26 2012 Detailed site examination notes are in the public docket The helicopter came to rest partially under the metal canopy of the fuel island which had a gash in it with tom metal sheets hanging down The height of the top of the mast of
103. idn t sound right that the engine was sputtering and that the engine power appeared to be increasing and decreasing The helicopter was observed rocking and teetering before nose diving toward the ground After the helicopter impacted the ground the engine continued to run and the tail rotor continued to spin A postaccident investigation revealed that the main transmission pinion had fractured and separated through the threads that retained the aft pinion nut Because the aft pinion nut maintained the position of the splined sleeve that drove the tail rotor drive shaft the separation of the pinion allowed the sleeve to wobble as it turned and to move aft partially disengaging its external splines from the intemal splines in the tail rotor drive shaft The sleeve s splines began to grind against the drive shaft s splines and the resulting material loss on the splines reduced the engagement between the parts to the point where a loss of tail rotor drive occurred It is likely that enough residual contact between the damaged splines remained to keep the tail rotor spinning as observed after impact but was not sufficient to deliver power to the tail rotor Examination of the pinion fracture surfaces determined that the pinion failure was due to a fatigue crack that initiated in a thread root and propagated through about 75 percent of the pinion s cross section before the remaining material succumbed to overstress conditions No indication of material d
104. ieved to be attributable to insufficient fuel pressure resulting from the backward surge in the fuel lines due to the forward acceleration of the airplane on takeoff Tests have shown that the cutting out tendency of the engine on takeoff can be eliminated by installing a revised fuel tank cap and following certain precautions during the takeoff operation As a result of this maintenance bulletin the airplane was required to be equipped with a placard reading Full carburetor air heat required for takeoff and Printed January 15 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 landing This placard was installed on the accident airplane and found during postaccident examination to be in good condition The TCDS also stated The reason for this placard is that during takeoff acceleration and initial high angle of attack climb the fuel flow may not be adequate for proper operation Application of full carburetor heat in this case helps overcome the possible deficiency of fuel flow during takeoff Carburetor ice is not a basic consideration in requiring this placard According to the Luscombe Endowment which maintains a technical resource library and provides s
105. ilot s FAA airman medical certification file and the pilot s personal medical records The toxicology evaluation identified quinine fluoxetine and its primary metabolite norfluoxetine in urine and fluoxetine 1 515 ug ml and norfluoxetine 1 036 ug ml in cavity blood Therapeutic levels for fluoxetine are 0 09 to 0 40ug ml but it can become concentrated in cavity blood post mortem Quinine is an antimalarial drug which is also found in tonic water At usual doses it does not affect performance Fluoxetine marketed under the trade name Prozac is an atypical antidepressant in the class of selective serotonin reuptake inhibitors Fluoxetine carries official FDA warnings Side effects of fluoxetine include insomnia anxiety and headache manic behavior and suicidal ideation have also been reported Warnings may impair mental and or physical ability required for the performance of potentially hazardous tasks e g driving operating heavy machinery Prescription bottles were found in the wreckage There were bottles with the pilot s name for fluoxetine Abilify aripiprazole Tramadol ultram Lyrica pregabalin and simvastatin Aripiprazole is used to treat bipolar disease and as an adjunct in major depression which is non responsive to first line treatments It carries a specific FDA warning use caution when operating machinery Printed January 15 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 71 P
106. investigator for light helicopters reported that an improper assembly of parts was observed on the accident helicopter The investigator revealed that the accident helicopter was not in compliance with the maintenance manual instructions in three areas the phenolic pinion plug 269A5441 was not properly installed the split bushing 269A5595 001 was missing and an incorrect longer 269A6030 BSC Spline Adapter was installed on the tail transmission Examination of Global Positioning equipment Under the supervision of the NTSB IIC the aircraft s Lowrance AIRMAP 2000C Global Positioning System unit was shipped to the NTSB Vehicle Recorder Laboratory in Washington D C for examination and analysis The specialist concluded that the recorded points did not conclusively capture the accident flight As such it was determined that the information on the device was not pertinent to the investigation Refer to the Vehicle Specialist s Factual Report which is appended to the docket Printed January 15 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 com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt WPR14CA057 11 23 2013 0 Regis N3151G Salt Lake City UT Acft Mk MdI NEW PIPER PA46 350P Acft Dmg Rpt S
107. ion Preflight inspection Pilot C 3 Personnel issues Action decision Info processing decision Decision making judgment Pilot F Narrative HISTORY OF FLIGHT On October 15 2012 at 1131 mountain standard time a Cirrus Design Corp SR20 N499SF landed hard during a forced landing in mountainous desert terrain near Suquilla Airport Parker Arizona The pilot was operating the airplane under the provisions of 14 Code of Federal Regulations CFR Part 91 The private pilot and passenger were not injured The airplane sustained substantial damage to the lower fuselage and both wings during the accident sequence The cross country flight departed John Wayne Orange County Airport Santa Ana Califomia at 0959 with a planned destination of Ernest A Love Field Airport Prescott Arizona Visual meteorological conditions prevailed and no flight plan had been filed The pilot stated that the first leg of the flight was from Santa Monica Municipal Airport earlier that moming and that prior to departure he visually established the fuel quantity through the filler necks observing what he believed to be full tanks He subsequently checked the fuel gauges which indicated that the wing tanks were each under half full He surmised that the gauges were faulty basing this assumption on the fact that the gauges of an airplane he had previously owned were inaccurate He subsequently departed for Santa Ana where he picked up a passenger Without refueling the airplan
108. ircraft Accident Incident Database Accident Rpt CEN11FA358 05 28 2011 2044CDT Regis N1041J Bryan TX Apt Easterwood Field Airport CLL Acft Mk MdI ROCKWELL 112 Acft SN 41 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING IO 360 C1D6 AcftTT 2937 Fatal 2 Serlnj 0 Fit Conducted Under FAR 091 Opr Name JOHN T HOLMSTROM Opr dba Aircraft Fire NONE Narrative HISTORY OF FLIGHT On May 28 2011 at 2044 central daylight time a Rockwell 112 single engine airplane N1041J impacted terrain during a forced landing at Bryan Texas The pilot and passenger were fatally injured No persons on the ground were injured The airplane sustained substantial damage The airplane was registered to a private individual and was being operated by another private individual for the 14 Code of Federal Regulations Part 91 personal flight Dusk visual meteorological conditions prevailed and a flight plan had not been filed The flight had originated from Fort Worth Spinks Airport FWS Fort Worth Texas about 1922 and was en route to Scholes Intemational Airport GLS Galveston Texas A witness statement and fueling records show that the airplane was last refueled on May 25 2011 Other records showed that the pilot made two flights of 1 4 hours each totaling 2 8 hours on May 26 2011 Another witness reported the pilot may have made two other local flights on either May 26 or May 27 2011 and records show the airplane was not refue
109. irplane was flying toward DOV between the final approach courses for runways 14 and 19 At 1843 the controller advised that DOV was at the pilot s 12 o clock position and 6 miles which the pilot acknowledged At 1844 the controller reported that the airplane was heading in the right direction and the pilot could expect to land on runway 14 The pilot replied that he was on to tower right now and no further communications were received from the accident airplane A GPS target was recorded at 1845 33 indicating the airplane was at 500 feet on an approximate 3 mile final for runway 14 PILOT INFORMATION The pilot held a private pilot certificate with ratings for airplane single engine land and instrument airplane The pilot received his instrument rating on June 9 2010 His most recent FAA third class medical certificate was issued on July 28 2011 Review of the pilot s logbook revealed that he had accumulated a total flight experience of approximately 598 hours of which about 77 hours and 35 hours were actual instrument and simulated instrument experience respectively The pilot had flown about 31 hours and 15 hours during the 90 day and 30 day periods preceding the accident respectively He flew 2 2 hours and 0 8 hours in actual instrument meteorological conditions during the 90 day and 30 day period respectively The pilot flew four instrument approaches and one instrument approach during the 90 day and 30 day period respectively The pilot
110. ist sheets are available to follow and track such checks they are not required to be completed or maintained under FAR Part 91 A maintenance logbook entry dated March 9 2012 at 1 481 4 hours 100 hours prior to the accident revealed that a replacement H frame was installed in conjunction with a 100 400 hour inspection A Sikorsky engineer reported that as a result of this inspection the pinion splines would have been exposed and that a torque check of the aft pinion nut would have been required METEROROLOGICAL INFORMATION At 1151 the weather reporting facility at the Phoenix Sky Harbor International Airport PHX Phoenix Arizona located about 4 nm south of the accident site reported wind 140 degrees at 9 knots visibility 10 miles few clouds at 20 000 feet scattered clouds at 25 000 feet temperature 31 degrees Celsius C dew point 1 degree C and an altimeter setting of 29 83 inches of mercury At 1153 the weather reporting facility at the Deer Valley Airport DVT Phoenix Arizona located about 11 nm north of the accident site reported wind 170 degrees at 8 knots gusts to 20 knots variable 130 degrees to 200 degrees 10 miles visibility sky clear temperature 28 degrees C dew point 2 degrees C and an altimeter of 29 85 inches of mercury WRECKAGE AND IMPACT INFORMATION A damage assessment of the helicopter was conducted at the operator s facility on May 24 2012 The airframe remained generally intact The steel main frame t
111. l rotor gearbox TGB remained on the tail boom adapter The tail rotor drive shaft was rotated and resulted in rotation of the tail rotor head This indicated that continuity existed from the drive shaft fracture at the MGB to the TGB output The chip detector was not examined The tail rotor drive shaft TRDS was fractured about 6 inches behind the main gear box MGB attach spline a minor torsional indication was observed The TRDS was bent at the forward tail boom bulkhead with minor indications of rotation The forward portion of the TRDS was extracted with no tools required and included the aft pinion nut a portion of the pinion and the driving spline The TRDS appeared intact and straight back to the TGB attach spline The aft bump stop was damaged and compressed from impact with the 269A6029 retention nut Minor wear was observed on the aluminum bumper and the nut The main gearbox remained attached to the airframe When the gearbox input was rotated the MR drive and rotor head tumed appropriately The upper pulley overrunning clutch rotated and engaged appropriately when tumed by hand The input pinion was observed to have been fractured and separated through the threads of the aft thread area The fractured pinion remained in the aft pinion nut and was secured by a cotter pin The phenolic spacer was not secured by the cotter pin was present but out of position and observed pressed into the pinion s hollow interior just forward of the fractur
112. l testing Continuity of both engine s crankshaft and valvetrain was confirmed through rotation of the propeller and thumb compression was confirmed on all cylinders The top spark splugs from both engines were removed and all exhibited normal wear and were grey to black in color Both propellers remained attached to their respective crankshaft flanges and both propeller spinners exhibited non torsional crush damage All of the propeller blades were bent aft about the mid span and each of the blades exhibited spanwise and chordwise scraping MEDICAL AND PATHOLOGICAL INFORMATION FAA Medical Records According to the pilot s FAA medical record he first received a third class medical certification in 1987 with a restriction for corrective lenses From that time forward until 2006 the pilot did not report use of any medications any medical problems or procedures or any traffic or non traffic convictions The single exception was a report of a physician visit and use of Axid nizatidine a proton pump inhibitor used to treat ulcers for heartburn in 1997 In 2006 the FAA received a safety hotline report that the pilot had previously had several convictions for drug possession and two convictions for driving while intoxicated Investigation revealed that the pilot had been convicted of misdemeanor charges for possession of marijuana in 1977 and 1978 and marijuana and hydrocodone a prescription narcotic and controlled substance in 1980 In addition he h
113. l to 3 500 feet pressure altitude Following departure from Santa Ana the airplane initiated a climb to 7 500 feet while on an east northeast track Twelve minutes later at 1011 the engine power reduced with its speed decreasing from 2 650 to 2 540 rpm and fuel flow falling from just under 17 gallons per hour gph to about 10 5 gph At 1114 54 the fuel flow decreased from 10 6 to 1 5 gph with a corresponding engine exhaust gas temperature EGT reduction of approximately 400 degrees F and a drop in engine speed of 250 rpm Over the course of the next 80 seconds the parameters recovered with the fuel flow rising to 16 6 gph before settling back to about 10 gph at 1117 Five minutes later the EGT fuel flow and engine rpm values all began oscillating and at 1123 30 the aircraft began a 1 000 feet per minute descent For the remainder of the flight the fuel flow dropped below 4 gph and the EGT fell below the recording limit of 500 degrees F Fuel consumption computed by the MFD for the accident flight was 17 4 gallons with the prior flight consumption computed as 5 5 gallons The airplane was equipped with two 28 gallon usable wet wing fuel storage tanks and a three position selector valve configured for the left tank right tank and OFF position The SR20 Pilot s Operating Handbook and FAA Approved Airplane Flight Manual defined the range endurance profile under the Performance Data section The data revealed that at a gross weight of
114. l was seen The three blade propeller displayed impact damage on the forward face of one blade which was bent aft about 90 degrees at mid span The other two propeller blades displayed superficial damage The propeller spinner had crushing damage but there was no evidence of rotation at impact The lower portion of the forward fuselage was crushed up and aft The cockpit area had crushing damage that reduced the occupiable space for the front seat occupants The fuel selector valve handle was observed in the BOTH position A J T Instruments EDM 700 engine data monitor and a Fujitsu Stylistic Tablet PC electronic flight bag computer were removed from the wreckage and sent to the National Transportation Safety Board s NTSB vehicle recorder division for examination MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot by the Travis County Office of the Medical Examiner in Austin Texas The cause of death was listed as blunt force injuries Forensic toxicology was performed on specimens from the pilot by the FAA Aeronautical Sciences Research Laboratory Oklahoma City Oklahoma The toxicology report stated NO CARBON MONOXIDE detected in Blood NO CYANIDE detected in Blood NO ETHANOL detected in Vitreous Fluoxetine detected in Blood and Urine Norfluoxetine detected in Urine and Blood Quinine detected in Urine The NTSB Chief Medical Officer reviewed the IIC s narrative the autopsy report the toxicology results the p
115. led after any of those flights On the day of the accident the airplane was in cruise flight about 9 500 feet mean sea level msl when the pilot advised the controller that he wanted to make a fuel stop at Easterwood Field Airport CLL College Station Texas The airplane then made a right turn of about 90 degrees and began descending toward CLL Several minutes later the pilot reported that he was running out of fuel When the airplane was at 600 feet msl the pilot reported that he would not make the airport A witness at an apartment complex reported seeing the airplane flying extremely low and parallel to the road when he saw it suddenly tum right and head toward the witness s location The airplane struck terrain and an unoccupied automobile in the parking lot of the apartment complex and came to rest upright 47 feet from the initial impact point PERSONNEL INFORMATION The 57 year old pilot held a private pilot certificate issued by the Federal Aviation Administration FAA with ratings for airplane single engine land and instrument airplane The pilot s flight review requirement was successfully completed on May 18 2010 A third class medical certificate was issued by the FAA on July 1 2010 As of May 26 2011 the pilot had logged a total of 460 6 hours of flight experience with 259 6 of those hours in the accident airplane make and model 18 2 of those hours were in actual instrument conditions an additional 49 9 of those hours
116. led signatures consistent with contact between the piston domes and the valves The crankcase halves were separated and the No 1 cylinder main bearing was rotated and damaged and distorted severely with bearing fragments located in the oil sump Bearing material was also extruded from its steel backing The No 3 cylinder main bearing showed accelerated wear and wiping of the bearing material Damage and signatures consistent with excessive heat due to oil starvation were observed on the No 1 and No 3 cylinder main bearing journals as well as the No 1 and No 2 cylinder connecting rod journals The camshaft gear was also damaged with five gear teeth sheared from the gear A review of engine maintenance records revealed that no maintenance had been performed on the engine that would have required breaking of crankcase thru bolt torques such as cylinder removal since its most recent overhaul which was completed more than 3 years and 314 flight hours before the accident flight The reason for the engine failure could not be determined because of the impact and postaccident fire damage Examination of the wreckage revealed that the landing gear was in the down and locked position the left engine propeller blades were in the feathered position and the left fuel selector valve was in the off position Examination of the manufacturer s Pilot Operating Handbook revealed that if properly configured with the landing gear retracted the airplane would have been
117. light controls and the autopilot were tested About mid flight the left alternator segment light illuminated and the ampmeter voltmeter showed a drop in voltage About 5 minutes later the light extinguished and the ampmeter voltmeter showed normal voltage for the remainder of the flight After landing the airplane was shut down and the accident pilot was told that the propeller rpm and the fuel flow needed adjustment on the left engine only There were also some cosmetic corrections that needed to be made After the corrections were made and prior to delivery of the airplane to the pilot a complete run up was performed and the maintenance records were reviewed to confirm all the work that was done during the annual inspection The airplane was equipped with two hydraulic pumps and therefore the hydraulic system would remain pressurized with only one engine operating METEOROLOGICAL INFORMATION At 1332 the weather reported at Palm Beach International Airport PBI 5 miles north of LNA included a scattered cloud layer at 2 600 feet and a broken Printed January 15 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 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database ceiling at 3 500 feet The wind was from 11
118. lity few clouds at 3 000 feet temperature 30 degrees Celsius C dew point 25 degrees C and an altimeter setting of 29 98 inches of mercury Printed January 15 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 The icing probability chart indicates there was potential for carburetor icing at glide and cruise power at the time of the accident AIRPORT INFORMATION Albert Whitted Airport was a tower controlled public use airport equipped with two runways oriented in a 07 25 and 18 36 configuration According to FAA records runway 7 25 measured 3 677 feet in length and 75 feet in width From the intersection with taxiway B the point at which the flight instructor stated the takeoff was initiated approximately 3 000 feet of runway takeoff distance available remained from runway 25 Obstructions included a 12 foot blast fence at the runway end a street 5 feet from the runway end and a 24 foot building 100 feet from the runway end WRECKAGE AND IMPACT INFORMATION The airplane came to rest inverted approximately 100 feet from the blast fence at the departure end of runway 25 The initial impact point was identified by a ground scar approximately one and a half feet
119. located about 13 nautical miles north of LEE At that time the closest paved runway was located about 6 nautical miles northwest of the airplane s position The Woods and Lakes Airpark FA38 Oklawaha Florida was equipped with a single 2 565 foot long by 36 foot wide asphalt runway No fuel services were available at FA38 Printed January 15 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 The airplane then began a gradual descent and when the pilot advised air traffic control that one of the airplane s fuel tanks was completely empty the airplane had traveled an additional 7 nautical miles south toward LEE but was still 6 nautical miles from the airport Data from the GPS ceased recording at 1435 38 about 1 100 feet northwest of the accident site and about 2 nautical miles north of LEE Printed January 15 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 Accide
120. ly contacted the LEE air traffic control tower at 1930 and advised the controller that the airplane was about 12 nautical miles north of the airport that the airplane was bingo fuel and that he would like a straight in approach to the runway The controller subsequently instructed the pilot to advise him when he was 1 mile from the runway on final approach When the airplane was about 6 nautical miles from the airport the pilot advised the controller that one of the airplane s fuel tanks was empty and that he was attempting to make it to the airport on one The controller then cleared the pilot to land on runway 13 but shortly thereafter the pilot advised the controller that the airplane was out of fuel and that they were going in No further transmissions were received from the pilot PERSONNEL INFORMATION According to airman records maintained by the FAA the pilot age 53 held a private pilot certificate with numerous ratings including airplane multi engine land Pilot logs recovered from the wreckage documented flight experience accumulated between 1987 and February 2005 During that time the pilot logged about 3 000 total hours of flight experience 1 400 hours of which were in multi engine land airplanes and 500 hours of which were in multi engine seaplanes The logs also contained endorsements for flight reviews completed in April 2008 and January 2012 AIRCRAFT INFORMATION The twin engine low wing retractable landing gear airplane w
121. mb out Shortly after the engine sputtered and lost engine power The pilot initiated a forced landing to the remaining runway while verifying the carburetor heat and mixture control positions Subsequently the airplane landed hard and came to rest upright Examination of the airplane by a Federal Aviation Administration FAA inspector revealed that the right wing was structurally damaged The wreckage was recovered to a secure location for further examination Examination of the recovered engine a Lycoming O 360 A4M serial number L 29230 36A revealed that the engine remained attached to the airframe via all its mounts All engine accessories remained attached to their respective mounts The engine crankcase and cylinder bases appeared to be coated with oil film All oil and fuel lines appeared to be intact and secure The exhaust and induction system was intact One propeller blade was bent aft about 20 degrees from midspan The carburetor was intact The throttle and mixture control cables remained attached to their respective control arms When actuated using the cockpit controls the throttle and mixture moved from stop to stop The top spark plugs and ignition leads were reinstalled The propeller was removed from the engine straightened and reinstalled on the engine The engine was started 3 times utilizing the magneto starter switch The engine ran at an idle power setting for approximately 5 to 10 seconds before shutting off The carburetor
122. mean sea level msl and a traffic pattern attitude of 1 800 feet msl According to a Federal Aviation Administration FAA inspector a Veteran s Day celebration was being held at the airport and the Stearman was the lead airplane in a flight of three Stearmans that planned to over fly the airport at an altitude of 1 800 feet mean sea level msl The pilot of the RV 12 reported that he overflew the airport at an altitude of about 2 000 feet msl and planned to enter a right downwind for runway 13 The Stearman reported that he was flying from south to north and planned to enter a right downwind for runway 13 continue to the northwest and maneuver back for a 360 degree turn over the runway Both pilots stated that they communicated their respective positions and intentions over the airport s common traffic advisory frequency CTAF In addition they were attempting to visually acquire each other when the two airplanes collided Both pilots were subsequently able to land their respective airplanes without further incident Examination of the airplanes by an FAA inspector revealed that the lower left side of the RV 12 s fuselage just aft of the cowling and the Stearman s rudder sustained substantial damage In addition the RV 12 s nose gear fairing also contained damage consistent with contact with the Stearman s rudder An approximate 20 inch portion of the top of the Stearman s rudder was folded to the left about 90 degrees A witness who was operati
123. mountain standard time a Hughes 269C helicopter N350TL sustained substantial damage after colliding with a residential home near Phoenix Arizona The helicopter was owned and operated by Canyon State Aero of Mesa Arizona The certified commercial pilot sustained serious injuries and the passenger sustained minor injuries Visual meteorological conditions prevailed and no flight plan was filed The reported photo flight was being operated in accordance with 14 Code of Federal Regulations Part 91 and a flight plan was not filed The local flight departed Deer Valley Airport DVT Phoenix Arizona about 1115 In a telephone conversation with the pilot as well as in a statement submitted to the National Transportation Safety Board NTSB investigator in charge IIC Printed January 15 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 the pilot reported that after picking up his passenger photographer he departed DVT for the construction site the photographer had been hired to photograph The pilot stated that after taking off he proceeded southwest toward the construction site about 500 feet above ground level agl and at an airspeed of between 70 to 75 knots
124. n for the Ka7 effective March 31 2006 which was to be completed in five year intervals This document defined the reason for inspection to be After an in flight wing failure inspections were carried out on all BGA registered Schleicher wooden gliders Urea formaldehyde adhesive had been used on all these gliders and had sometimes suffered from failure apparently due to a combination of age and damp conditions Glued joint deterioration has been found in sufficient numbers of these gliders to warrant an ongoing inspection program There were no records of the wing inspection being completed on the accident glider The FAA did not issue an Airworthiness Directive related to this issue TESTS AND RESEARCH The outboard section of the right wing was sent to the National Transportation Safety Board NTSB Materials Laboratory in Washington D C for further examination The examination revealed the wood wing section was fractured and splintered in multiple places Cracks were observed on many of the adhesive joints The condition of the adhesives was degraded and poor The upper and lower spar caps were constructed of three and two layers of wood respectively Both were covered in a urea formaldehyde adhesive and were Printed January 15 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
125. n wheels were conventionally operated by applying toe pressure to the top of the rudder pedals with the rotation of the pedals actuating the brake master cylinders which would result in braking action on the main wheels The tailwheel steering was controlled through the tailwheel steering arms by cables and bellcranks attached to the rudder control cables Tailwheel steering of 24 degrees left and right was available and for tighter tums application of toe pressure on either rudder pedal would cause the tailwheel to free swivel enabling the airplane to be pivoted around the wheel being braked The tailwheel was also equipped with an anti swivel locking system which could be engaged by the pilot to limit steering to 2 5 degrees left and right Examination of the rudder system brake system and tailwheel steering systems revealed that with the right rudder pedal arm separated from the right rudder pedal bar that right rudder right brake and right tailwheel steering would not have been available Interior Care According to the Cessna 188 Owner s Manual care of the interior of the airplane was as important as the care of the exterior The primary factors to be considered being cleanliness of the cockpit area and freedom from dirt and corrosion throughout the entire airframe advising that Some dirt and toxic chemicals will find its way into the fuselage through long periods of use these hazards must be minimized if the pilot is to operate the airpl
126. nal Transportation Safety Board Aircraft Accident Incident Database Accident Rpt ERA14CA080 12 28 2013 0 Regis N2056J White Plains NY Acft Mk MdI SCHWEIZER 269C Acft Dmg Rpt Status Prelim Prob Caus Pending Fatal 0 Serlnj 0 Opr Name Opr dba Aircraft Fire Printed January 15 2014 ann 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 CEN13LA218 03 29 2013 1445EDT Regis N2065P Cleveland OH Apt Burke Lakefront KBKL Acft Mk MdI SCHWEIZER 269C 1 Acft SN 0140 Acft Dmg SUBSTANTIAL Rpt Status Prelim Prob Caus Pending Eng Mk Mdl LYCOMING HIO 360 G1A Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name JW HELICOPTER LLC Opr dba Aircraft Fire NONE Narrative On March 29 2013 about 1445 eastern daylight time a Schweizer 269C 1 helicopter N2065P experienced a hard landing at the Burke Lakefront Airport KBKL Cleveland Ohio The helicopter was substantially damaged The private pilot was not injured The helicopter was registered to and operated by JW Helicopter LLC under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight The local flight departed KBKL at an unknown time According to inf
127. ng the Unicom CTAF frequency at GA2 stated that the pilot of the RV 12 reported inbound via an overhead to the right downwind for runway 13 He advised the pilot of the RV 12 of two other aircraft entering the downwind for runway 13 who then stated that he would execute a 360 and re enter the traffic pattern The witness was observing an airplane clear the runway after landing when heard the pilot of the Stearman report inbound from the Printed January 15 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 southeast for a practice fly by About 1 minute later the pilot of the RV 12 reported entering the downwind for runway 13 He subsequently observed the Stearman approaching from the south and the RV 12 approaching from the southeast He asked the Stearman if they had the RV 12 insight however just as he released the microphone key the two airplanes overlapped He could not tell the approximate position of the two airplanes to each other from his vantage point and initially believed they experienced a near miss The accident was not captured on radar however both pilots reported that they were utilizing handheld Garmin global positioning system GPS receivers
128. no change The pilot s most recent medical certificate third class was issued on July 1 2010 with a limitation must have available glasses for near vision The only medication then reported by the pilot was simvastatin marketed under the trade name Zocor TESTS AND RESEARCH Wreckage examination The wreckage was moved to another location and examined The engine and cowling were still attached The wings had been cut at the root and the tail section had been removed to facilitate transport All components of the airplane were present Both wings were examined and neither wing had any blue fuel staining or displayed any hydraulic deformation Both wing fuel tanks were opened and examined Both fuel tank transmitters were examined and a resistance test was performed on the transmitters it was noted that the left wing transmitter functioned nominally the right wing transmitter was observed to indicate the aircraft right side fuel gauge would read empty when there were approximately five gallons remaining in the tank All three primary flight controls were examined Control cable continuity was confirmed from the main wing spar aft for the Rudder and Elevator Aileron flight control continuity was verified from the fuselage to wing mate cut lines to both the left and right ailerons The engine was removed from the airplane and the engine and all components were examined Approximately one quarter of an ounce of aviation fuel was recovered f
129. nt Rpt WPR13FA054 11 25 2012 2308 PST Regis N4204A Corona CA Apt Corona AJO Acft Mk Mdl ROBINSON HELICOPTER COMPANY R44 Acft SN 12634 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING I0 540 AE1A5 Acft TT 133 Fatal 1 Serlnj 0 Fit Conducted Under FAR 091 Opr Name LAW OFFICES OF JAMES C BECHLER Opr dha Aircraft Fire GRD PC Narrative HISTORY OF FLIGHT On November 25 2012 at 2308 Pacific standard time a Robinson R44 II N4204A collided with a fueling structure at Corona Municipal Airport Corona California The pilot owner was operating the helicopter under the provisions of 14 Code of Federal Regulations CFR Part 91 The commercial pilot sustained fatal injuries the helicopter sustained substantial damage from impact forces and post crash fire The cross country personal flight was departing Corona for Fullerton Califomia Instrument meteorological conditions prevailed and no flight plan had been filed A friend stated that he picked the pilot up at French Valley Airport in Temecula California about 1630 and they had attended an event in Temecula He dropped the pilot back off at the airport about 2200 Witnesses at Corona reported to first responders that they heard the helicopter and then a bang followed by an explosion They went outside and observed the helicopter on fire Fueling records indicated that the pilot added 40 6 gallons of 100LL about 15 minutes before the accident A review of a securi
130. nt with underlying fatigue striations The engineer reported that the pinion fracture surface displayed a variety of ratchet marks indicative of multiple fatigue crack initiations The fatigue crack initiated at a thread root consistent with the area of highest stress concentration on the part No material deficiencies such as inclusions pits or voids were found at the crack initiation site The engineer opined that the features of the fracture surface suggest that after initiation the fatigue crack progressed rotationally while other cracks initiated ahead of the crack on the outer surface of the pinion in the thread root Once the crack grew to sufficient size the remaining cross section succumbed to overstress Approximately 0 25 inches of the fracture surface exhibited dimple rupture indicative of overstress No indications of other failure mechanisms such as intergranular cracking were observed The forward faces of the pinion threads were relatively undamaged and showed no indications of contact wear with the adjacent nut The aft faces of the threads displayed rotational wear to approximately half of the depth of the thread root The aft thread tips showed indications of fretting wear and minor material loss No indication of mechanical damage or contact was found in the valleys of the pinion threads Refer to the Material Laboratory Factual Report No 13 023 which is appended to the docket During the investigation a Sikorsky accident
131. o airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt ERA13FA082 12 08 2012 1334EST Regis N297DB Lake Worth FL Apt Palm Beach County Park Airport LNA Acft Mk Mdl CESSNA 421C Acft SN 42100826 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl TELEDYNE CONTINENTAL MOTORS AcftTT 7040 Fatal 1 Serlnj 0 Fit Conducted Under FAR 091 Opr Name SUBWAY DEVELOPMENT OF Opr dba Aircraft Fire GRD SOUTHEAST FLORIDA INC AW Cert STN Summary The twin engine airplane was released to the pilot who was also the airplane owner after an annual inspection and repainting of the airplane had been completed Before the accident flight which was the second flight after maintenance the pilot performed an engine run up for several minutes before taxiing to the end of the departure runway for takeoff According to witnesses the airplane lifted off about halfway down the runway and initially climbed at a normal rate Several witnesses then observed the airplane suddenly yaw to the left for 1 or 2 seconds and the airplane s nose continued to pitch up before the airplane rolled left and descended vertically nose down until it disappeared from view One witness a flight instructor said The airplane just kept pitching up and then it looked like a VMC the airplane s minimum controllable airspeed with only one engine operating roll Examination of the left engine revea
132. o evidence of preimpact mechanical malfunction was noted during the examination of the recovered airframe and engine Reference the examination report filed in the public docket for additional details Printed January 15 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 11 National Transportation Safety Board Aircraft Accident Incident Database Accident Rpt WPR14CA090 01 04 2014 0 Regis N76463 Marana AZ Acft Mk MdI CESSNA 140 Acft Dmg Rpt Status Prelim Prob Caus Pending Fatal 0 Serlnj 0 Opr Name Opr dba Aircraft Fire Printed January 15 2014 ann 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 Accident Rpt WPR14CA069 12 13 2013 0 Regis N7015F Henderson NV Acft Mk MdI CESSNA 150F Acft Dmg Rpt Status Prelim Prob Caus Pending Fatal 0 Serlnj 0 Opr Name Opr dba Aircraft Fire Printed January 15 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 13 Prepared From Official
133. ogical conditions prevailed at the time and no flight plan was filed VFR flight following was obtained The flight originated from Danbury Municipal Airport Danbury CT about 1440 The pilot stated that the flight departed with full fuel tanks and after takeoff proceeded to the Statue of Liberty which he orbited twice He then climbed to 1 500 feet and while in contact with the FAA LaGuardia control tower he noticed the engine was not developing power Because he had switched fuel tanks 30 minutes into the flight while at the Statue of Liberty he turned on the auxiliary fuel pump and switched the fuel selector to the fuel tank selected for takeoff He stated that he could not recall the tank selected for takeoff In attempt to restore engine power he also richened the mixture and pushed the throttle full in but with no affect He declared a mayday established best glide airspeed and was vectored to a nearby airport but realized he would be unable to land there He observed an expressway with 2 closed lanes and maneuvered the airplane for landing He did not make contact with any trees or light poles on approach to the expressway In preparation for the forced landing he shut off the fuel and magnetos and cracked the cabin entry door After coming to rest all occupants exited the airplane Printed January 15 2014 an airsafety com e product Copyright 1999 2012 Air Data Research Page 53 Prepared From Official Records of the NTSB By All Rights
134. ol ATC radar and voice communication information provided by the Federal Aviation Administration while approaching TPA the pilot advised ATC that the airplane s engine was experiencing difficulties and that he needed to land the airplane on an alternate runway The pilot was subsequently cleared to land on runway 19R The crew of a helicopter operated by the Tampa Police Department observed the airplane as it approached and impacted a berm short of the runway on the airport property The helicopter crew then landed adjacent to the accident site and one of the crewmembers successfully extracted the pilot from the wreckage An examination of the airframe and engine were scheduled for a later date Printed January 15 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 ERA13LA005 10 02 2012 900 EDT Regis N8025M Burlington VT Apt Burlington BTV Acft Mk Mdl CESSNA 3101 Acft SN 31010025 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl CONTINENTAL MOTORS INC 10 470U AcftTT 3675 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name KYLE B CLARK Opr dba Aircraft Fire NONE Summary The pilot reported that he landed
135. om 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 Accident Rpt CEN13FA213 03 30 2013 1600 CDT Regis N12053 Littlefield TX Apt Littlefield Municipal Airport KLIU Acft Mk Mdl SCHLEICHER ALEXANDER K7 Acft SN 7205 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Fatal 2 Serlnj 0 Fit Conducted Under FAR 091 Opr Name EDDIE HOGLAN Opr dba Aircraft Fire NONE Narrative HISTORY OF FLIGHT On March 30 2013 about 1600 central daylight time a Schleicher Alexander Ka7 glider N12053 impacted terrain following an inflight wing separation near the Littlefield Municipal Airport KLIU Littlefield Texas The commercial pilot and passenger were fatally injured The glider was destroyed The glider 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 and no flight plan was filed The local flight originated from KLIU about 1545 According to witnesses of the accident the glider was riding thermals when it appeared to come out of a thermal and execute a tight loop They heard a loud sound and then saw the glider spinning to the ground The glid
136. ormation collected by the responding Federal Aviation Administration inspector while landing at the airport the helicopter landed hard and was substantially damaged Printed January 15 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 ERA12FA491 08 01 2012 1400 EDT Regis N2761K St Petersburg FL Apt Albert Whitted Airport KSPG Acft Mk Mdl SILVAIRE LUSCOMBE 8A Acft SN 5488 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl CONT MOTOR A amp C65 SERIES Fatal 1 Serlnj 1 Fit Conducted Under FAR 091 Opr Name JAMES A FINNEGAN Opr dba Aircraft Fire NONE Summary The sport pilot had recently purchased the accident airplane and was working with a flight instructor for familiarization because he had not flown during the past 30 years The flight instructor stated that he and the pilot had flown seven or eight flights together before the accident flight and that the pilot had previously flown about 5 hours with another flight instructor During the accident flight the pilots took off from a runway intersection The flight instructor stated that the engine seemed to be producing full power until the airplane reached an altitud
137. orological conditions VMC prevailed at the time of the accident While operating in VMC pilots are required to maintain vigilance and to see and avoid other aircraft Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS The inadequate visual lookout by the pilots of both airplanes which resulted in a midair collision Events 1 Approach Midair collision Findings Cause Factor 1 Personnel issues Psychological Attention monitoring Monitoring other aircraft Pilot C 2 Personnel issues Psychological Attention monitoring Monitoring other aircraft Pilot of other aircraft C Narrative On November 10 2012 about 1055 eastem standard time an experimental amateur built Vans RV 12 RV 12 N678AD and a Boeing E75 Stearman N1370V both operated by private individuals collided in midair while on approach to the Peach State Airport GA2 Williamson Georgia The private pilot in the RV 12 and the airline transport pilot in the Stearman were not injured Visual meteorological conditions prevailed and no flight plans were filed for either flight The RV 12 departed the Covington Municipal Airport CVC Atlanta Georgia The Stearman departed Seven Lakes Airport 62GA Jackson Georgia Both airplanes were operated as personal flights in accordance with 14 Code of Federal Regulations Part 91 Peach State airport was a privately owned non towered airport with an elevation of about 930 feet
138. oted The fuel tank was filled to capacity containing 14 gallons of fuel The flight was cleared for takeoff from runway 25 at the intersection with taxiway B with the owner conducting the takeoff The flight instructor reported that the carburetor heat control was in the off position for maximum takeoff power and that the engine was producing full power during the takeoff roll until it reached an altitude around 100 feet above ground level Shortly thereafter the flight instructor noted an audible loss of power that was confirmed by the tachometer which varied from 1 800 to 2 100 rpm He stated that the engine seemed to roll back and did not sputter or run rough The airplane began to descend the pilot owner applied carburetor heat and the flight instructor assumed control of the airplane With insufficient runway remaining on which to land and the presence of obstacles at the end of the runway straight ahead the flight instructor attempted to maneuver the airplane towards the ramp to the south of the runway The airplane subsequently impacted the runway in a nose down attitude and came to rest inverted The flight instructor stated that he attempted to tum the fuel selector valve to the off position prior to egressing the airplane but could not remember if he had successfully done so The flight instructor then egressed and assisted in extricating the pilot owner from the wreckage Four witnesses observed the airplane as it was taking off They
139. oted that the left wing navigation light appeared to be inoperative The witnesses stated that as the airplane neared the departure end of runway 30 at an altitude of about 400 feet agl it rolled to the left and descended in a vertical attitude below their line of site behind a row of hangars Examination of the accident site revealed that the airplane impacted terrain about 490 feet southwest of the departure end of runway 30 All major structural items of the airplane were located within about 50 feet of the main wreckage except for a portion of the outboard left fiberglass wingtip Numerous white paint chips landing light lens cover fragments and a portion of the left fiberglass wingtip was located about 1 406 feet southeast of the threshold of runway 30 A tree about 62 feet in height exhibited numerous broken branches about 40 to 45 feet above the ground The wreckage was recovered to a secure location for further examination Printed January 15 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 0 Regis N80238 Fullerton CA Acft Mk MdI CESSNA 172M Acft Dmg Rpt Status Prelim Prob Caus Pending Fatal 0 Serlnj 0 O
140. pared 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 produce fine fuzz Emergency Procedures The emergency procedures section of the RHC Pilot s Operating Handbook POH for the R44 series recommends the following action in the event of a main rotor gearbox chip light indication Indicates metallic particles in main rotor gearbox NOTE If light is accompanied by any indication of a problem such as noise vibration or temperature rise land immediately If there is no other indication of a problem land as soon as practical Dynamic Rollover RHC Safety Notice SN 9 issued in June 1994 was included in the POH and stated the following regarding dynamic rollover A dynamic rollover can occur whenever the landing gear contacts a fixed object forcing the aircraft to pivot about the object instead of about its own center of gravity The fixed object can be any obstacle or surface which prevents the skid from moving sideways Printed January 15 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 A
141. perated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a solo cross country flight Visual meteorological conditions prevailed and a visual flight rules flight plan had been filed but was unopened for the flight destined for the Bremerton National Airport PWT Bremerton Washington The student pilot reported that he was on the return leg of his first solo cross country flight About 20 minutes into the flight he was flying at an altitude of about 3 500 feet above ground level agl when the weather started to deteriorate He descended to an altitude of about 2 500 feet agl and proceeded to the nearest airport that was reporting better weather En route he observed that the vertical speed indicator indicated a descent of 700 feet per minute The pilot applied full power but the airplane continued to descend he elected to land onto a nearby road During the descent he ensured that the mixture was full rich the fuel selector was on both fuel tanks and the throttle was at full power The pilot made a left traffic pattern around the road and just before he turned base he tumed on the carburetor heat As he turned final he observed that the airplane was too high he idled the throttle and initiated a slip to lose altitude During the landing flare the airplane struck a sign along the left side of the road departed the roadway and came to rest inverted about 20 feet from the road surface During the accident sequence the left
142. pilot added power and taxied the airplane back to the runway and then subsequently taxied to the ramp 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 airplane control after encountering an unexpected wind gust during landing Events 1 Landing flare touchdown 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 general Not attained maintained C 2 Personnel issues Task performance Use of equip info Aircraft control Pilot C 3 Environmental issues Conditions weather phenomena Wind Gusts Awareness of condition Narrative On July 10 2012 about 0930 mountain daylight time MDT N30753 a Cessna 177B airplane was substantially damaged while landing at the Gooding Municipal Airport GNG Gooding Idaho The certified private pilot sustained serious injuries and the sole passenger was not injured Visual meteorological conditions prevailed at the time of the accident The personal cross country flight was being operated in accordance with 14 Code of Federal Regulations Part 91 and a visual flight rules VFR flight plan had been filed and was active a
143. pr Name Opr dba Aircraft Fire Printed January 15 2014 ann airsafety com e product _ Copyright 1999 2012 Air Data Research Page 17 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 WPR13LA402 09 09 2013 1328 PDT Regis N42EP Long Beach CA Apt Long Beach daugherty Field LGB Acft Mk MdI CESSNA 172N Acft SN 17269777 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl LYCOMING 0 320 SERIES AcftTT 9486 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name WERNTZ DAVID G Opr dba Aircraft Fire NONE Narrative On September 9 2013 about 1328 Pacific daylight time a Cessna 172N N42EP was substantially damaged during a forced landing following a reported loss of engine power at the Long Beach Airport Long Beach Califomia The airplane was registered to and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91 The commercial pilot sole occupant of the airplane was not injured Visual meteorological conditions prevailed and no flight plan was filed for the local personal flight which originated from the El Monte Airport El Monte Califomia about 1130 The pilot reported that following a touch and go landing on runway 25L he began a normal cli
144. ps up or continued flight may be impossible Using weather conditions that were current at the time of the accident interpolation of the airplane manufacturer s RATE OF CLIMB ONE ENGINE INOPERATIVE chart revealed that with the landing gear retracted and the propeller on the inoperative engine feathered the airplane was capable of an approximate climb rate of 400 feet per minute With the landing gear down and locked as found the airplane was capable of an approximate climb rate of 50 feet per minute The FAA Airplane Flying Handbook defined VMC as Minimum control speed The minimum flight speed at which the airplane is controllable with a bank of not more than 5 degrees into the operating engine when one engine suddenly becomes inoperative and the remaining engine is operating at takeoff power At low airspeed and high power conditions the downward moving propeller blade of each engine develops more thrust than the upward moving blade When the right engine is operative and the left engine is inoperative the tuming force is greater In other words directional control is more difficult when the left engine the critical engine is suddenly made inoperative Printed January 15 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
145. pter with fuel departed and flew towards Hollywood The flight then continued west to Santa Monica and back inland over the Universal Studios Theme Park Forest Lawn Cemetery and the HOLLYWOOD sign From there they transitioned past the Griffith Observatory flying east about 1 700 feet msl mean sea level The flight instructor stated that a few seconds later the Main Rotor Gearbox Chip MR Chip warning light illuminated The helicopter continued to operate normally without any unusual sounds and he immediately began looking for an area to land The flight instructor observed a potential landing site to the left adjacent to a trail on the southem slopes of Griffith Park As he approached the helicopter began making a whining sound that he had never heard before He could see people on the intended landing spot so he turned the helicopter left towards the north following a ridgeline in an effort to find an alternate landing site He followed the ridge back around to the southwest and spotted a small clearing on a pinnacle at the end of a trail He initiated a descent while maneuvering the helicopter onto a west heading They landed on the clearing and before he had a chance to fully lower the collective control he felt the helicopter slip He then raised the collective and the helicopter immediately spun to the right and rolled over HELICOPTER INFORMATION The helicopter was manufactured in September 2006 and was equipped with its original
146. ransportation Safety Board Aircraft Accident Incident Database Accident Rpt WPR14CA083 12 31 2013 0 Regis N369JJ Salinas CA Acft Mk MdI CESSNA 195A Acft Dmg Rpt Status Prelim Prob Caus Pending Fatal 0 Serlnj 0 Opr Name Opr dba Aircraft Fire Printed January 15 2014 san 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 WPR13CA409 09 14 2013 1545 Regis N4324N Meadow Creek MT Apt Meadow Creek Usfs 0S1 Acft Mk MdI CESSNA 195A UNDESIGNAT Acft SN 7085 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl JACOBS L4 R755 7 AcftTT 5139 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name LEIGHTON ALEXANDER C Opr dba Aircraft Fire NONE Narrative The pilot reported that during the takeoff roll on a rough turf runway the airplane bounced and swerved to the right The pilot corrected for the swerve when the airplane bounced a second time and despite his inputs the airplane departed the left side of the runway The right wheel encountered a depression and collapsed subsequently the right wing struck the ground and sustained substantial damage The pilot reported no preimpact mechanical failures or malfunction
147. rass The airplane s right wing was substantially damaged The pilot reported no preimpact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation Printed January 15 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 Accident Rpt WPR13LA011 10 15 2012 1131 MST Regis N499SF Parker AZ Apt Parker P20 Acft Mk Mdl CIRRUS DESIGN CORP SR20 Acft SN 1540 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl CONT MOTOR 10 360 SER AcftTT 1714 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name ROBERT A LIPSON Opr dba Aircraft Fire NONE Summary Before the first flight of the day the pilot visually checked the airplane s fuel quantity through the fuel tank filler necks observing what he believed to be full tanks He subsequently checked the fuel gauges which indicated that both wing tanks were less than half full Surmising that the gauges were faulty the pilot departed on a short flight to a local airport to pick up a passenger After picking up the passenger they departed for a cross country flight He did not refuel the airplane before that departure and after travelling for about 90
148. rcent with a tailwind of 10 percent of the airplane takeoff speed The POH listed a liftoff speed of 65 knots A tailwind of 6 5 knots would be expected to increase the landing distance by about 165 feet Therefore the calculated landing ground roll on a 2 percent runway downslope with a 6 5 knot tailwind and using maximum braking would be expected to be less than 1 000 feet Printed January 15 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 Accident Rpt ERA14LA083 01 01 2014 1400 CDT Regis N351AE Alabaster AL Apt N a Acft Mk MdI BELLANCA 17 30A Acft SN 73 30577 Acft Dmg SUBSTANTIAL Rpt Status Prelim Prob Caus Pending Eng Mk Mdl CONT MOTOR IO 520 SERIES Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name ELOM ANTHONY W Opr dba Aircraft Fire NONE Narrative On January 1 2014 approximately 1420 central standard time a Bellanca 17 30A N351AE was substantially damaged during a forced landing following a total loss of engine power in Alabaster Alabama The private pilot incurred minor injuries Visual meteorological conditions prevailed and no flight plan was filed for the flight which departed Bessemer Airport EKY Bessemer Alabama
149. rch 9865 Tower View Helotes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database leading edges with corresponding impact scars on the ground The right wing was bent up and aft at mid span Both wings remained attached to the fuselage and no hydraulic deformation was observed to either wing No fuel was detected in the fuel tank in either wing The left and right wing flaps remained attached Both ailerons remained attached or partially attached The left and right main landing gear were impact damaged but observed to be retracted and still in the gear wells The nose gear was impact damaged and was protruding slightly out of the nose gear well The rear empennage remained attached to the fuselage and was bent slightly over the top portion of the fuselage in scorpion tail fashion The elevator trim tab was observed in the neutral position The elevator and rudder remained attached with no significant damage noted The engine remained attached to the fuselage and the propeller remained attached to the engine The bottom of the engine cowling displayed impact and crushing damage and the engine mount was bent slightly up The upper engine cowling was detached and found with other debris near the main wreckage The gascolator was examined and had a small amount of clean aviation gasoline The fuel screen was clear The flow divider was opened and examined and no fue
150. related emergency which resulted in a loss of engine power due to fuel exhaustion Events 1 Approach IFR final approach Fuel exhaustion 2 Approach IFR final approach Loss of engine power total 3 Emergency descent Off field or emergency landing 4 Emergency descent 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 Action Incorrect action performance Pilot C 3 Personnel issues Action decision Info processing decision Decision making judgment Pilot C 4 Personnel issues Action decision Action Delayed action Pilot C Narrative HISTORY OF FLIGHT On January 13 2013 about 1845 easter standard time a Piper PA 28R 200 N4975S operated by a private individual was substantially damaged during a forced landing following a total loss of engine power while on approach to Dover Air Force Base DOV Dover Delaware The private pilot was fatally injured Night instrument meteorological conditions prevailed and an instrument flight rules flight plan was filed for the planned flight to Summit Airport EVY Middletown Delaware The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91 and originated from Kaolin Field OKZ Sandersville Georgia about 1330 Review of the pilot s flight plan revealed an estimated time enrou
151. repared 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 Ultram is a synthetic opioid pain reliever used to treat moderate to severe pain Concomitant administration of ultram and selective serotonin reuptake inhibitors has been demonstrated to increase the risk of seizure and serotonin syndrome In addition ultram carries a specific FDA waming may impair the mental and physical abilities required for the performance of potentially hazardous tasks such as driving a car or operating machinery Pregabalin is indicated as treatment for pain and to prevent partial complex seizures It carries a specific FDA warning may cause dizziness and somnolence and impair patient s ability to drive or operate machinery The FAA s toxicology lab does not test for pregabalin The ultram was an as needed medication and may not have been taken recently The dosing regimen for the aripiprazole had been increased by the physician only a few weeks before the crash According to the pilot s personal medical records the pain medications were prescribed for a nerve impingement syndrome in his neck and shoulder Records show intermittent use of antidepressants and anxiety medications from 1989 forward In January 2011 although he was already taking fluoxetine the pilot suf
152. retor ice It is likely that pilot did not apply carburetor heat during the airplane s descent landing or ground operations and did not detect any carburetor ice accumulated during those operations before the ensuing takeoff Based on the available information it is likely that an accumulation of carburetor ice resulted in the partial loss of engine power during takeoff Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS A partial loss of engine power during takeoff likely due to the accumulation of carburetor ice Events 1 Takeoff Loss of engine power partial 2 Takeoff rejected takeoff Collision with terr obj non CFIT Findings Cause Factor 1 Environmental issues ConditionsAveather phenomena Temp humidity pressure Conducive to carburetor icing Contributed to outcome C Narrative On November 20 2012 about 1700 central standard time a Boeing A75L3 N56226 was damaged when it overran the end of the runway and struck trees after an aborted takeoff from runway 35 at the Horizon Airport 74R San Antonio Texas The pilot reported a loss of engine power which precipitated the aborted takeoff The pilot and passenger were not injured The airplane sustained substantial damage to the upper left wing spars The aircraft was registered to an individual and operated by the commercial pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight Visual me
153. rial removal were observed on the outer teeth of the driving spline along with chatter and circumferential gouging on the outer forward surface The chatter marks were located where a roller bearing is normally in contact with the driving spline The engineer s report revealed that the splines exhibited some loss of material the amount varied from negligible to almost 50 percent of the cross sectional area and the largest difference in loss was 180 degrees apart In contrast the interior splines of the part were relatively undamaged and exhibited no appreciable loss of material Some rubbing was observed on the forward interior of the part mirroring the exterior shape of the pinion The engineer further reported that the angle of material removed on the drive spline outer splines mirrored that of the wear and material loss on the mating interior splines of the forward sections of the tail rotor drive shaft The damage on the interior splines was rotational in nature but was not as severe as on the driving spline the material loss was confined to an approximately 90 degree area The engineer also noted that the forward faces of the splines exhibited some smearing and material loss in a counterclockwise direction forward looking aft Printed January 15 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 780
154. ring the power loss event thus based on the available information it is likely that the airplane s engine lost power due to carburetor icing Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS The pilot s failure to use carburetor heat while operating in conditions conducive to carburetor icing which resulted in a partial loss of engine power shortly after takeoff Events 1 Takeoff Loss of engine power partial 2 Emergency descent Collision with terr obj non CFIT Findings Cause Factor 1 Environmental issues Conditions weather phenomena Temp humidity pressure Conducive to carburetor icing Contributed to outcome 2 Personnel issues Task performance Use of equip info Use of equip system Pilot C Narrative On August 3 2012 about 0919 central daylight time a Weatherly 620B N2008S sustained substantial damage when it impacted the ground following a loss of engine power during takeoff from a field near Holcomb Kansas The pilot received minor injuries The aircraft was owned and operated by Farmers Aviation Inc under the provisions of 14 Code of Federal Regulations Part 137 as an agricultural application flight Visual meteorological conditions prevailed for the flight which was not operated on a flight plan The local flight was originating at the time of the accident The pilot reported that he completed a preflight examination and pre takeoff run up of the airplane with
155. rom the gear Examination of maintenance records revealed that the manufacturer s main bearings and rod bearings were installed in the engine during overhaul Further examination of the records revealed that no maintenance was performed on the engine that would have required breaking of crankcase thru bolt torques such as cylinder removal since overhaulThe item 98 write up on the most recent annual inspection invoice stated Investigate no oil pressure on left engine reprime left oil pump filter standpipe When interviewed the proprietors at the maintenance facility said that the airplane s engines sat idle for an extended period weeks due to the annual inspection and the painting of the airplane Because engine oil has a tendency to settle in the sump and cause the oil pump to lose its prime the engines were motored When motored the left engine showed no oil pressure The oil system was then primed and oil pressure was restored prior to engine start Examination of maintenance records revealed that as of the most recent inspection all Airworthiness Directives were complied with and up to date ADDITIONAL INFORMATION The manufacturer s normal procedure for TAKEOFF 1 Power SET FOR TAKEOFF2 Mixtures CHECK fuel flows in the white arc3 Engine Instruments CHECK4 Air Minimum Control Speed 80 KIAS5 Takeoff and climb to 50 feet 100 KIAS at 7450 pounds The manufacturer s normal procedure for AFTER TAKEOFF 1 Landing Gear RETRACT2 Best
156. rom the inlet fuel screen housing of the fuel injector The fuel sample tested negative for the presence of water No other fuel was observed in the engine An unmeasured amount of oil was observed in the oil sump and there was no evidence noted of thermal distress or lubrication distress The postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal Printed January 15 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 operation Examination of devices containing non volatile memory NVM The airplane was equipped with a J T Instruments EDM 700 engine data monitor EDM which records several engine parameters including fuel flow exhaust gas temperature EGT The EDM device was examined at the NTSB vehicle recorder division in Washington D C and data was extracted EDM data for the accident flight showed that fuel flow increased to about 20 gallons per hour about nine minutes after the start of data at an estimated takeoff time of 1922 About 22 minutes later the fuel flow decreased and for about the next 50 minutes it remained at an average of about 14 7 gallons per hour
157. s fatally injured and the pilot rated passenger was seriously injured Visual meteorological conditions prevailed and no flight plan was filed for the flight which departed Eagles Nest Aerodrome FD44 Crescent City Florida at 1405 and was destined for Leesburg Intemational Airport LEE Leesburg Florida The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91 According to the pilot rated passenger who was also the pilot s wife the pilot completed the preflight inspection of the airplane and prepared for their departure while she was shopping Upon retuming home she boarded the airplane secured the aft cabin door and prepared the cabin for departure as she would normally do prior to any other flight She then sat down in the front right seat of the airplane about the time the pilot had taxied onto the runway Shortly after Printed January 15 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 com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database takeoff and while reading through the after takeoff checklist she noticed that the fuel quantity in the left and right fuel tanks appeared to be low with the left gauge reading slightly above 1 4 tank of fuel and the righ
158. s old included an overcast ceiling of 300 feet The pilot thanked the controller for the information and continued to fly to GED At 1816 the pilot reported that he was established on the approach The published minimum for the GPS approach to runway 22 at GED with LPV was 360 feet msl 310 agl The pilot flew that approach to a GPS altitude of 250 feet and at 1826 reported that he was on a missed approach requested the same approach again and advised that he was running low on fuel The controller then asked the pilot if he was going to need an altemate airport and the pilot asked if there was anything easier than the approach at GED The controller replied that he could try Delaware Airpark 33N Dover Delaware The controller added that 33N used DOV weather recording which was currently visibility 10 miles and ceiling 500 feet overcast At 1830 while being vectored for an approach at 33N the pilot asked if there was any chance he could land at DOV The controller replied negative sir unless it s an emergency there is no way you can land here At 1835 the pilot was cleared for the VOR RWY 27 approach at 33N At 1841 the pilot declared an emergency and reported that he was out of fuel At that time the controller provided vectors for the ILS runway 19 approach at DOV however the airplane was about 2 000 feet msl 7 miles north of DOV and had to reverse course as it was flying north away from the airport After completing the tum the a
159. s with either the airplane or the engine prior to or during the flight that would have precluded normal operation At 0953 the weather reporting facility at the Jerome County Airport Idaho JER Jerome Idaho which is located about 18 nautical miles southeast of the accident site reported wind 100 degrees at 9 knots with no gusts reported Printed January 15 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 Accident Rpt ERA13LA410 09 04 2013 1835 EDT Regis N59JK Woodrow SC Apt Hopkins Air Field NONE Acft Mk Mdl CESSNA 188B Acft SN 18801041 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl CONT MOTOR O 470 R AcftTT 5393 Fatal 0 Serlnj 0 Fit Conducted Under FAR 137 Opr Name ROBERT E HOPKINS JR Opr dba HOPKINS FLYING SERVICE Aircraft Fire NONE Narrative HISTORY OF FLIGHT On September 4 2013 about 1835 eastern daylight time a Cessna 188B N59JK operated by Hopkins Flying Service was substantially damaged during landing roll after a flight control malfunction at a private airport in Woodrow South Carolina The commercial pilot received minor injuries Visual meteorological conditions prevailed for the aerial appli
160. s with the airframe or engine that would have precluded normal operation Printed January 15 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 Accident Rpt ERA14LA076 12 19 2013 2351 EST Regis N5307A Tampa FL Apt Tampa International Airport TPA Acft Mk MdI CESSNA 210N Acft SN 21063360 Acft Dmg SUBSTANTIAL Rpt Status Prelim Prob Caus Pending Eng Mk Mdl CONTINENTAL MOTORS I0 520L AcitTT 21788 Fatal 0 Serlnj 1 Fit Conducted Under FAR 135 Opr Name AIRNET SYSTEMS INC Opr dba Aircraft Fire GRD Narrative On December 19 2013 at 2351 eastern standard time a Cessna 210N N5307A was substantially damaged during a forced landing following a total loss of engine power while on approach to Tampa International Airport TPA Tampa Florida The commercial pilot was seriously injured Visual meteorological conditions prevailed and the airplane was operating on an instrument flight rules flight plan The flight had originated from Valdosta Regional Airport VLD about 2307 and was destined for TPA The on demand air cargo flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 135 According to preliminary air traffic contr
161. t Incident Database Accident Rpt WPR14CA082 12 29 2013 0 Regis N924JS Roberts MT Acft Mk MdI CUBCRAFTERS INC CC11 160 Acft Dmg Rpt Status Prelim Prob Caus Pending Fatal 0 Serlnj 0 Opr Name Opr dba Aircraft Fire Printed January 15 2014 an airsafety com e product _7 7 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 WPR14CA086 01 03 2014 0 Regis N5484U Shaw Island WA Acft Mk Md DEHAVILLAND BEAVER DHC 2 MK 1 Acft Dmg Rpt Status Prelim Prob Caus Pending Fatal 0 Serlnj 0 Opr Name Opr dba Aircraft Fire Printed January 15 2014 ann 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 Accident Incident Database Accident Rpt WPR14CA043 11 03 2013 0 Regis N1550R Avalon CA Acft Mk Mdl GRUMMAN AMERICAN AVN CORP AA 5B Acft Dmg Rpt Status Prelim Prob Caus Pending Fatal 0 Serlnj 0 Opr Name Opr dba Aircraft Fire Printed January 15 2014 ann airsafety com e product _
162. t found in Federal Aviation Administration Special Airworthiness Information Bulletin CE 09 35 entitled Carburetor Icing Prevention the reported temperature and dew point fall in the range of susceptibility for icing during glide and cruise power settings and within the range of susceptibility for serious icing during glide power Printed January 15 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
163. t gauge reading slightly below 1 4 tank of fuel When the passenger queried the pilot about the fuel quantities the pilot replied that the left fuel gauge always indicated a greater quantity of fuel than the right gauge and that if the fuel quantity in the right tank became too low they could always use fuel from the left fuel tank She continued to closely monitor the fuel quantity state and fuel flow to both engines for the next 10 minutes About that time and about 6 miles north of LEE the right engine began to surge The pilot responded by repositioning the right engine s fuel selector from the inboard to the outboard fuel tank He then contacted the air traffic control tower at LEE requested to land and advised the controller that the airplane was running low on fuel Shortly after making that transmission the left engine began to surge and the pilot again responded by repositioning the fuel selector from the inboard to the outboard fuel tank The pilot then began searching for an off airport landing site and during the descent both engines operated intermittently The pilot later advised air traffic control that the airplane was going down prepared for a forced landing to a field below and extended the airplane s landing gear The airplane subsequently struck trees short of the pilot s intended landing area According air traffic control voice communication information provided by the Federal Aviation Administration FAA the pilot initial
164. t the time of the accident The flight departed the Yakima Air Terminal McAllister Field YKM Yakima Washington about 0630 MDT with GNG as its destination In a postaccident conversation as well as in a report submitted to the National Transportation Safety Board investigator in charge the pilot reported that no adverse winds were reported as she monitored the UNICOM frequency about 10 miles out while proceeding inbound to GNG The pilot stated that when she reported 3 miles and 2 miles from the airport no turbulence was encountered and that the approach was on the center line of the runway and the glide path and that the approach was normal The pilot further stated that after crossing over the approach end of the runway she pulled the power to idle and began to flare at which time the airplane s left wing was abruptly pushed upward This was followed by the right main tire contacting the runway the nose wheel hitting the runway and the left main landing gear hitting the runway hard The pilot reported that the airplane then bounced into the weeds off the right side of the runway before going into a small ditch The pilot added that she was able to add power and managed to get the airplane back up on the runway and taxi to a fixed based operator s facility where she inspected the airplane The pilot reported that the firewall was bent and the left side of the fuselage was wrinkled The pilot further reported that there were no mechanical anomalie
165. t was issued a first class special authorization interim issuance medical certificate due to hyperthyroidism A review of the pilot s log book revealed that the pilot had accumulated a total of 937 7 hours 39 4 hours of multiengine time and 24 4 hours in the make and model of the accident airplane He obtained his multiengine land rating on April 28 2012 AIRCRAFT INFORMATION The twin engine low wing six seat retractable landing gear airplane was manufactured in 1961 with the serial number 27 413 It was powered by two 250 horsepower Lycoming O 540 A1D5 engines driving metal two blade constant speed Hartzell HC A2VK 2 propellers The airplane s last annual inspection was conducted on August 31 2012 at a total airframe time of 6 076 35 hours The left engine s starter cable was replaced on the day of the accident There was no record of any other recent maintenance performed on the airplane Printed January 15 2014 an airsafety com e product Copyright 1999 2012 Air Data 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 METEOROLOGICAL CONDITIONS At 1453 an automated weather reporting facility at KTYR reported wind from 130 degrees at 11 knots 10 miles visibility few clouds at 5 000 feet temperature 90 degrees F
166. tatus Prelim Prob Caus Pending Fatal 0 Serlnj 0 Opr Name Opr dba Aircraft Fire Printed January 15 2014 ann airsafety com e product _ 7 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 Accident Rpt CEN13LA111 12 19 2012 1700 CST Regis N3134G Graham TX Apt Graham Municipal KRPH Acft Mk Mdl PIPER L 18C Acft SN 52 2419 Acft Dmg SUBSTANTIAL Rpt Status Factual Prob Caus Pending Eng Mk Mdl CONT MOTOR C90 12F AcftTT 2987 Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name PIERCE CHRISTOPHER G Opr dba Aircraft Fire GRD AW Cert STN Summary The pilot was returning to the airport when the engine experienced a total loss of power As the pilot maneuvered to perform a forced landing the engine seized and the propeller stopped The airplane landed hard bounced and nosed over coming to rest inverted The airplane sustained substantial damage to the wings and rudder An examination of the engine revealed that a connecting rod failed and broke through the crankcase which resulted in a loss of oil and the subsequent loss of engine power The reason for the failure of the connecting rod could not be determined Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD D
167. te a few landings and then continue to Miami According to the mechanic the pilot performed a ground run of the airplane for several minutes before taxiing to the approach end of Runway 3 for takeoff The airplane lifted off about halfway down the runway and climbed at a normal rate The mechanic then observed the airplane suddenly yaw to the left for a second or two and the airplane s nose continued to pitch up before rolling left and descending vertically nose down until it disappeared from view Several witnesses provided similar accounts to a Federal Aviation Administration FAA inspector and the local sheriff s department One witness a certificated flight instructor said The airplane just kept pitching up and then it looked like a VMC roll PERSONNEL INFORMATION The pilot held a commercial pilot certificate with ratings for airplane single engine land and sea airplane multiengine land and instrument airplane His most recent FAA third class medical certificate was issued on February 27 2008 An examination of the pilot s logbook revealed that he had logged 1 217 total hours of flight experience of which 175 hours were in multiengine airplanes AIRCRAFT INFORMATION According to FAA and maintenance records the airplane was manufactured in 1980 Its most recent annual inspection was completed December 3 2012 at 7 039 9 aircraft hours The airplane had accrued 2 2 hours of flight time after the inspection The No 2 right engine w
168. te of 3 hours 45 minutes with 5 hours 30 minutes of fuel onboard The pilot filed for a cruising altitude of 5 000 feet mean sea level msl and listed an alternate airport of Baltimore Washington International Airport BWI Baltimore Maryland Review of fueling records revealed that the pilot completely fueled the airplane before departing on the accident flight According to information provided by the U S Air Force Federal Aviation Administration FAA and obtained from a handheld GPS the airplane was in radio and radar contact with Dover Approach at 1647 while descending for a GPS approach to EVY Printed January 15 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 The controller advised the pilot that a previous airplane had to fly a missed approach at EVY due to weather then flew another missed approach at Wilmington Delaware before diverting again At 1649 the pilot asked the controller what the weather was at Salisbury Regional Airport SBY Salisbury Maryland The controller replied that the 1629 recording included a ceiling that was 400 foot overcast and a visibility of 8 miles The pilot replied that he wanted to try an approach at SBY The controll
169. teorological conditions prevailed for the flight which was not operated on a flight plan The flight originated from the Stinson Municipal Airport SSF about 1650 The pilot stated that the flight began at SSF and an uneventful landing was performed on runway 16 at 74R The airplane was turned around at the end of the runway for a takeoff from runway 34 The pilot reported that the winds were calm at this time After liftoff at about 15 feet above the ground the pilot recognized that the airplane was not producing adequate power and was not accelerating and he landed the airplane The airplane touched down near the departure end of runway went off the end of the runway and struck trees A witness stated that the airplane landed on runway 16 made a 180 degree turn at the end of the runway and departed from runway 34 The witness said that he saw the airplane become airbome and when it was about 20 to 30 feet above the ground it leveled off and appeared to lose power On scene examination of the airplane by a Federal Aviation Administration Airworthiness Inspector did not reveal any anomalies that would account for the loss of engine power The engine was able to be rotated by hand and the intake and exhaust valves functioned normally The engine oil level was normal and no oil was found in the engine s exhaust Fuel was present in the fuel tank The fuel shutoff valve was found in a partially closed position but fuel flowed freely through the fuel strain
170. ter the initial inspection had been accomplished and then every 600 hours of operation A Supplemental Inspection Document SID was also included in the Service Manual that listed items that were to be examined after 12 000 hours or 20 years whichever occurred first after the initial inspection had been accomplished for airplanes operating in a typical usage environment Furthermore the Service Manual included items for airplanes that were operated in a severe usage environment including aerial application that were to be examined after the first 6 000 hours of operation or 10 years whichever occurred first with the inspection to be repeated every 1 000 hours of operation or 5 years whichever occurred first Examination of the Service Manual IPC CPCP and SID also revealed that guidance regarding corrosion inspection and corrosion control of the rudder system was included which contained information regarding rudder attachment hinge brackets hinge bolts and hinge bearings the rudder structure rudder skins ribs forward and aft spars and torque tube the rudder pedal torque tube and cable attachments and the rudder cable system control cables and pulleys Materials Laboratory Examination Examination of the rudder pedal assemblies by the NTSB Materials Laboratory revealed that on the outboard side of the right rudder pedal the right rudder pedal arm was affixed to the pedal arm cross shaft using a cotter pin and modified fender
171. tes Texas 78023 210 695 2204 info airsafety com www airsafety com National Transportation Safety Board Aircraft Accident Incident Database One of the main rotor blades remained attached to the teeter hinge and sustained bending damage midspan The second blade exhibited downward curling damage along its entire length had separated about 2 feet from the teeter hinge and came to rest against the tailboom The outboard leading edge sustained chordwise abrasions with the adjacent trailing edge skin and honeycomb core separating from the spar The tip cap mounting bolt remained attached to the spar with remnants of the tip cap still attached but the bulk of the cap was not present The immediate area surrounding the wreckage was searched but the tip cap was not located Examination of the landing spot revealed multiple ground disruptions consistent with main rotor blade contact as well as a 4 foot long ground disturbance just below the crown of the peak on the opposite side of the main wreckage A growth of dry grass and brush bordered the disturbance additionally the left landing skid s toe exhibited longitudinal abrasions to its forward and upper surfaces TESTS AND RESEARCH The helicopter was removed from the accident site and examined at a remote storage facility The flight control system was examined and was intact through to the horizontal firewall All remaining flight controls exhibited varying degrees of bending damage and separ
172. th engines remained attached to the wing mounts The left engine was fractured in multiple places The left propeller fractured at the first crankshaft web One blade displayed leading edge polishing deep nicks gouges and chordwise scratches The opposite blade had leading edge polishing and chordwise scratches from the blade root to near mid span where it was displayed aft The right engine s crankcase was fractured in multiple locations The right propeller hub remained attached to the engine and one blade had fractured from the hub Both blades displayed curling leading edges nicks and gouges and chordwise scratches Flight control continuity was established from the flight controls to the rudder and elevators and to the aileron bellcranks The cockpit section was fragmented tom and displaced The left engine s tachometer displayed 1 650 rpm with a Hobbs time of 315 4 hours and the right engine s tachometer displayed 1 450 rpm with a Hobbs time of 313 8 hours Most of the other cockpit instruments were unreadable or destroyed MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot by Forensic Medical Management Services of Texas as authorized by the Justice of the Peace Precinct 2 Smith County Texas The cause of death was blunt force injuries and the manner of death was ruled an accident Forensic toxicology was performed on specimens from the pilot by the FAA Bioaeronautical Sciences Research Laboratory Oklahoma City Okla
173. the R44 was 129 inches 10 75 feet the rotor radius was 198 inches 16 5 feet The canopy was 14 feet above the ground The helicopter sustained severe fire damage from the mid tail boom forward Fire consumed most of the cabin area The main rotor blades sustained impact and thermal damage One main rotor blade spar separated investigators located it in a hangar several hundred feet from the main wreckage The main rotor gearbox separated from the airframe with deformation and separation in the frame tubes Fracture surfaces were jagged and angular The tail rotor driveshaft had disconnected aft of the intermediate flex plate and exhibited damage that was associated with severe thermal damage to the tail cone The tail rotor blades sustained minor impact damage There was rotational scoring at the tip of both tail rotor blades There was a semi circular ground scar with red paint transfer that arched counter clockwise toward the tail section MEDICAL AND PATHOLOGICAL INFORMATION The Riverside County Coroner completed an autopsy They ruled that diffuse thermal injury and inhalation of products of combustion were the causes of death The FAA Forensic Toxicology Research Team Oklahoma City Oklahoma performed toxicological testing of specimens of the pilot Analysis of the specimens contained no findings for carbon monoxide cyanide volatiles and tested drugs TESTS AND RESEARCH Investigators from the NTSB FAA Robinson Helicopter Comp
174. the multiengine airplane without incident however while taxiing after landing the left main landing gear collapsed which resulted in substantial damage to the left wing and left horizontal stabilizer Subsequent examination of the airplane revealed that the left main landing gear bellcrank pin had separated from its bushing The pin was not located however metallurgical examination of the left main landing gear bellcrank and retraction link revealed significant deformation and fracturing of the bellcrank bushing which was consistent with a very large force applied along the axis of the link The deformations on the link suggested that the pin fractured inside the hole and exited the bore as two separate pieces Although an overstress failure seems probable other failure modes such as a significant fatigue crack cannot be ruled out because the fractured pin fragments were not located The airplane was manufactured about 38 years before the accident It had been operated for about 3 675 total hours about 25 hours of which occurred since its most recent annual inspection which was performed about 2 months earlier Cause Narrative THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS The collapse of the left main landing gear due to a failure of the left main gear bellcrank pin for reasons that could not be determined because the pieces of the fractured bellcrank pin were not located Events 1 Taxi from runway L
175. ty video showed that the helicopter was facing towards a fuel island and the cabin was partially under a circular metal canopy that covered the island The helicopter lifted off and made an immediate pedal tum nose right Nearing 180 degrees of turn the helicopter pitched forward the tail and main rotor blades came up and contacted the metal canopy The helicopter then began to flail while tuming and came to rest after it turned 180 degrees right back in the original direction Several seconds later a fire began that was followed a few seconds later by an explosion PERSONNEL INFORMATION A review of Federal Aviation Administration FAA airman records revealed that the 61 year old pilot held a commercial pilot certificate with ratings for airplane single engine land rotorcraft helicopter and instrument airplane The pilot held a certified flight instructor CFI certificate with a rating for airplane single engine land The pilot possessed a third class medical certificate issued on October 23 2012 it had no limitations or waivers No personal flight records were located for the pilot The NTSB investigator in charge IIC obtained the aeronautical experience listed in this report from a review of FAA records on file in the Airman and Medical Records Center located in Oklahoma City The pilot reported on his medical application that he had a total time of 1 500 hours with 50 hours logged in the previous 6 months AIRCRAFT INFORMATION The hel
176. ubes were broken distorted and bent in various locations The aft cabin wall was distorted aft on the left side The main rotor mast support tube on the left side of the aircraft exhibited a mid span compression fold The aft support tube fractured and was separated at the mast and the tailboom support fitting The right landing gear was observed entirely separated from the helicopter The left side landing gear dampers remained attached to the aircraft and the strut was attached to the skid tube Both landing gear skid tubes were fractured at the forward strut attach points The forward cross beam was fractured near its mid point while the aft cross beam was intact but bent down near the right side cluster fitting The tailboom was intact but observed separated at the forward bulkhead by a compression fracture The tailboom tube appeared straight with minor denting on the top near the forward end The horizontal stabilizer was intact and remained attached with minor denting noted The vertical fin was crushed from contact to the bottom and was bent to the right The left side support strut was intact with the right side support strut separated forward of mid span by a folding fracture Both support tubes exhibited scratches and markings on the bottom consistent with asphalt shingle material Impact damage was consistent with a high vertical velocity wings level nose low impact attitude with the roof of the house followed by a nose over into the yard
177. upport to Luscombe owners and operators the use of carburetor heat on takeoff and landing is required in 8A airplanes equipped with 65 or 75 hp engines and a single fuselage fuel tank It states that in low fuel conditions one half tank or less and on a cool day it is possible to achieve an angle of climb wherein the engine fuel inlet is higher than the fuel tank outlet resulting in a disruption of fuel flow to the engine The use of carburetor heat effectively reduced the power output of the engine thus prohibiting the airplane from achieving such an angle of climb Printed January 15 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 Accident Rpt WPR14LA079 12 27 2013 1055PST Regis N8848K Lodi CA Apt Kingdon Airpark 020 Acft Mk Mdl STINSON 108 1 Acft SN 108 1848 Acft Dmg SUBSTANTIAL Rpt Status Prelim Prob Caus Pending Eng Mk Mdl FRANKLIN 6A4150 SERIES Fatal 0 Serlnj 0 Fit Conducted Under FAR 091 Opr Name BRYANT FLOYD H Opr dba Aircraft Fire NONE Narrative On December 27 2013 about 1055 Pacific standard time a Stinson 108 1 airplane N8848K experienced a loss of engine power and the pilot made a forced landing in an open field near Lod
178. washer and bolt nut assembly which was not specified in either the Service Manual or IPC When the fender washer was removed from the right rudder pedal an elongated hole due to adhesive wear was discovered The inboard side of the right rudder pedal was also discovered to be affixed to the pedal arm cross shaft using a cotter pin and bronze bushing Neither of which was specified in either the Service Manual or IPC Further examination also revealed that the bushing was not part of the originally manufactured rudder pedal assembly and it had been inserted through a hole which had been drilled into the inboard side of the right rudder pedal Examination of the silicone plugs which had been applied and cured as a thixotropic paste in the top of the left and right rudder pedal arms revealed that remnants of corrosion product had adhered to the silicone plugs indicating that corrosion product was present before the application of the silicone resin occurred Examination of the right rudder pedal arm for corrosion also revealed that the external surfaces of the right rudder pedal arm exhibited areas with disbonded topcoat paint and exposed steel with minor surface corrosion Internally however the right rudder pedal arm exhibited heavy rust scaling over all surfaces and rust scale which had sloughed from the surfaces had collected at the base of the right rudder pedal arm where it attached to the right rudder bar Also though Measurements of the tube wall t
179. were in simulated instrument conditions and a total of 18 8 hours of night flight time AIRCRAFT INFORMATION The four seat low wing retractable gear airplane serial number s n 41 was manufactured in 1973 It was powered by a 200 hp Lycoming O 360 C1D6 engine serial number L 9193 51A which drove a Hartzell 3 blade metal alloy controllable pitch propeller The engine was equipped with a pilot controlled manual waste gate turbo normalized system manufactured by RCM Normalizing Inc installed under FAA Supplemental Type Certificate Number SE5203NM Printed January 15 2014 an airsafety com e product Copyright 1999 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 The airplane had fuel tanks in each wing which had a total useful fuel capacity of 62 gallons The aircraft maintenance logbooks were not available for examination However the pilot s aircraft usage spreadsheet pilot s personal logbook and several individual flight planning documents were found in the wreckage The investigator in charge IIC reviewed those documents and estimated that the most recent annual inspection was completed on May 24 2011 at a tach time of 2 937 18 hours which is the IIC s estimate of the aircraft total time
180. wing and empennage were substantially damaged A post accident visual inspection of the engine revealed no visual anomalies The cylinder rocker covers and spark plugs were removed when compared to the Champion AV 27 chart the spark plug electrode areas were consistent with normal wear The valves were undamaged and contained no abnormal thermal discoloration Cylinder compression and valve continuity was obtained from all cylinders The removed engine components were reinstalled and the engine was prepared for an engine test run The airplane was started and idled temporarily before it was operated at various RPMs There were no noted mechanical failures or malfunctions with the airplane s engine The nearest weather reporting station Sanderson Field Airport in Shelton Washington was located at about 11 miles to the east of the accident scene At Printed January 15 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 2353 weather was reported as few clouds at 1 700 feet agl broken clouds at 4 200 feet agl and overcast clouds at 5 500 feet agl light rain 10 miles of visibility temperature 4 degrees C dewpoint 4 degrees C and an altimeter setting of 30 07 in

General Aviation Reports - John Eakin

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